HomeMy WebLinkAboutMiscellaneous - 544 JOHNSON STREET 4/30/2018 544 JOHNSON STREET
210/038.0-0048-0000.0
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
- CITY I NORTH ANDOVER MA DATE L8-22-16 1 PERMIT#
JOBSITE ADDRESS 1544 JOHNSON ST OWNER'S NAME I MICHEAL DONNELLY
GOWNER ADDRESS I SAME I TEI,5 8-932-3254 IFAXI
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONALF1 RESIDENTIAL El
PRINT
CLEARLY NEW:[] RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES® NOD
APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE L�j I__...LLi
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR { _ _
I 0-1-
17--1
FURNACE
GENERATOR I. _r.
GRILLE
INFRARED HEATER
LABORATORY COCKS s -
MAKEUP AIR UNIT _
OVENI^_ �7- i
POOL HEATER
ROOM I SPACE HEATER I �..� � _�9�_-wl-_ . '--, _ II. _ i DL—All�
ROOF TOP UNIT -- � I_ L � 1 I �- I
TEST
UNIT HEATER -
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑NO ❑
1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITYF-1 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 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 rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME I JAMES BURKE LICENSE# 10469 SIGNATURE
MP n MGF® JP❑ JGF❑ LPGI❑ CORPORATION Q# 2727C PARTNERSHIP❑#L= LLC❑#��i
COMPANY NAME: BURKE&SONS PLG&HTG INC ADDRESS PO BOX 102
CITY I GROVELAND I STATE MA ZIP 01834 TEL978-374-7837
FAX 978-373-6615 1 CELL 978-360 4453 EMAILjim@burkeandsonsplumbing.com
L,_;j
/I_. The Commonwealth of Massachusetts
Department of Industrial Accidents
Off-ice of Investigations
600 Washington .street
Boston,AL4 02111
Uf www.mass.gov/diva
Workers' Compensadon Insurance Affidavit- Bu illde>rs/cContmeltors/IElectiricians/Plluna>mbe>rs
Apj2liean>t Information Please Prip ]Legibli
Name (Business/Organization/individual): GQA.�e- c,-- Az
Address: P- / -0---
City/State/Zip: 11Y-47Je-L`4�, Phone 4A —_3 71— 7�d-7
Are ou an employer? Check the appropriate box: Type of project(required):
1.T 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.❑ 1 am a sole proprietor or partner-
listed 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. 9. ❑ Building addition
No workers' comp. insurance 5• ❑ We are a corporation and its
[ P 10.❑Electrical repairs or additions
required.] officers have exercised their
3. 1 am a homeowner doing all work g exemption tion
right of per MGL 11.WPlumbing repairs or additions
❑
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I 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: C'rLr_ 1AYtr4S
Policy#or Self-ins. Lic. #: (ala d r)(P3 l i Expiration Date:
of� � S
Job Site Address:_ 5 44 ��Al DA,� �,&j "ity/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 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 andpenalties of perjury that the information provided above is true and correct
5Si1 nature: Date: — Z A
Phone4: �����340
Official use onl:,Oi
not write in this area,to be completed by city or town official
City or Town: ]Permit/license#
Issuing Authorrcle one):
1. Board of)H[e . ]Building(Department 3. City/Town Clerk 4.]Electrical flnspector 5.Plumbing flnspector6. Other
Contact Perso )Phone#:
n�
C\- MASSACHUSETTS UNIFORM APP L Com-ON FOR A PERMIT TO PERFORM PLUMBING WORK
u,p CITY I NORTH ANDOVER MA DATE 8-22-16 j PERMIT#
JOBSITE ADDRESS 1544 JOHNSON ST OWNER'S NAME MICHAEL DONNELLY
POWNER ADDRESS I SAME TELI 508-932-3254 FAX
TYPE
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Q
PRINT
CLEARLY NEW:E] RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES® NO[]
FIXTURES-1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 *13 14
BATHTUB
CROSS CONNECTION DEVICE 1
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK _
TOILET
URINAL
WASHING MACHINE CONNECTION _
WATER HEATER ALL TYPES 1
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[] NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
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 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.
PLUMBER'S NAME I JAMES BURKE LICENSE# 10469 SIGNATURE
MP❑ JP® CORPORATION# 2727 PARTNERSHIP®# LLC F]#
COMPANY NAME I BURKE&SONS PLG&HTG ADDRESS I PO BOX 102
CITY FGROVELAND STATE MA ZIP 01834 TEL 978-374-7837
FAX 978-373-6615 CELL 978-360-4453 1 EMAIL jim@burkeandsonsplumbing.com
v, I
7l'Bae C®arae¢oaaweaN:�;rmassachaasetts
_ Department of Industrial Accidents
I
Office of Investigations
600 Washington Street
Boston,3M 02111
5Y �' www.mass.gov/dila
Workers' Compensation Insurance Affidavit: BuniRders/Cont melto rs/IE9ectric>ians/Plunmbe>rs
Applicant Infform2ti®n Please P)U ]Le ihfl
Name (Business/organization/Individual):
t)
Address: PD
City/State/Zip: ( J e-�A�^ Phone#:
AFl
ou an employer? Check the appropriate box: Type of project(required):
1. 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 7 ❑Remodeling
[2.❑ I am a sole proprietor or partner listed on the attached sheet.
These sub contractors have 8. ❑ Demolition
ship and have no employees
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
No workers' comp, insurance 5• ❑ We are a corporation and its
[ p• 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work g exemption tion
right of per MGL I I.YPlumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑Roof repairs
insurance required.] t employees. [No workers' 13 ❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
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'comppolicy in
d am an employer that is providing workers'compensation insurance for my employees. below is the policy and job site
information.
Insurance Company Name: ('i2 rYlAyt,4,T
Policy#or Self-ins. Lic.#: "LY(71p 6 ' Expiration Date:
Job Site Address: S/LJ ��-> XZ-D b �� AAAOICYL' City/State/Zip:01'6'45
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 andpenalties of perjury that the information provided above is true and correct
nSi ature: Date:
Phone : 360414�5
Official use only. Do not write in this area,to be completed by city or town official
City or'flown: Permit/License#
Issuing Authority(circle one):
1. board of health 2. building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. ®they
Contact Person: Phone#:
8/22/2016 *Gas Permit#21184-UewPoint Cloud
�� I Oc' 6
*Gas Permit - Replacement of Existing Fixtures/Appliances (Commercial of Residential)
TIMELINE
O
Submission received
Aug 22,2016 at 12:57pm
OGas
Permit
Review
In Progress
OPermit Fee
Payment
OPermit
Issuance
Document
https://northandoverma.%Aewpointeloud.conV#/records/21184 1/6
8/22/2016 *Gas Permit#21184-ViewPoint Cloud
Your request is in progress
We'll let you know of any updates via email. Feel free to check the status at any time by coming back to this page.
*Gas Permit #21184 Replacement of Existing Fixtures/Appliances(Commercial of Residential)
r.�
Applicant Location
james burke 544JOHNSON STREET , NORTH ANDOVER, MA
Owner
DONNELLY, MICHAEL)
Attachments
No Files...
Primary Contractor
Search for your contractor using the search bar below. Either the Firm's Name or licensee# is required.
i
https://northando\,erma.\.iewpointcloud.con-VWrecords/21184 2/6
8/22/2016 *Plumbing Permit#21185-ViewPoint Cloud
7.1 "U" 80-1 ts
*Plumbing Permit - Replacement of Fixture/Appliance (Commercial or Residential)
TIMELINE
OSubmission
received
Aug 22,2016 at
1:01 Pm
OPlumbing
Permit Review
In Progress
OPermit Fee
Payment
OPermit
Issuance
Document
Your request is in progress
https:Hnorthando,,erma.,.iewpointcloud.com/Wrecords/21185 1/6
8/22/2016 *Plumbing Permit#21185-ViewPointCloud
We'll let you know of any updates via email. Feel free to check the status at any time by coming back to this page.
*Plumbing Permit #21185 Replacement of Fixture/Appliance(Commercial or Residential)
•
r.x
Applicant Location
james burke 544JOHNSON STREET , NORTH ANDOVER, MA
Owner
DONNELLY, MICHAELJ
Attachments
No Files...
Primary Contractor
Search for your contractor using the search bar below. Either the Firm's Name or licensee# is required.
Firm's(Business) Name Plumber's Name(Licensee)* License#* License Type:* License Expiration Date* License Active License Status
James A Burke 10469 Master Plumber 04/30/2018 Active
https://northando\,errna.\iewpoi ntcl oud.com/#/records/21185 216
c
Date..............?...................
Ot t,,O o7 s 1ti
3? �•� �,� TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
CMUSEt
This certifies that ........... .....z ...............
has permission to perform .......... J`,zW-01.C.ip....... Alzl< .............
wiring in the building of.........6.P.l .�Z/ELL. ...................................
at......... .4�. 4��! i' ±.�..... 5.r...... ... ,North Andover,Mass.
• ®o
Fee =.. Lic.Nol. � .
.. ........ ..../. ... . !:..
LECTRICAL INSPE R
.....'
Check #
commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
# BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/07] Qeave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WOR
All work to be performed in accordance with the Massachusetts Electrical Code(MEC);527 CMR 12.00
(PLEASE PRW BV' NK OR TYPE ALL INFORMATI019 Date: — 7 10
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)_ .�'�� � � � �0�2 ��--•
Owner or Tenant
Telephone No.
Owner's Address D/v 6uf—L
Is this permit in conjunction with a building permit?
Purpose of Building Yes El No ❑ (Check Appropriate Boa)
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:
Completion o the olloxnn table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans 0.0 Total
No.of Luminaire Outlets Transformers KVA
No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above F-1 ,In_ o.o Emergency ig g
d• d• Bo.
Units
--, No,of Receptacle Outlets No.of oil Burners
. FUZE ALARMS. No.of?.ones
No.of Switches No.of Gas Burners No.of Detection and
No.of Total
No.of Air Cord.
Ranges —12mitiating Devices
Tons No.of Alerting Devices
No.of Waste Disposers eat Pump Number Tons _ No.of Self-Contained
Totals; "" Detection/Ale ' Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal
No.of Dryers HeatingA Connection ❑ Other
Appliances KW Security Systems:
No.of WaterNo. No.of Devices or E uivalent
of
Heaters KW Bal of Data Wiring:Signs Ballasts . No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Tom Telecommnnications icing;
OTHER; No.of Devices or E uivalent
Attach additional detail tf desired, or as required by the Inspector of Wires.
Estimated Value of El ctrl 1 Work:
Work to Start (When required by municipal policy.)
7 l Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE CO GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation"coverage or its substantial equivalent The
undersigned certifies that such cove ge is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE W BOND ❑ OTHER ❑ (Specify:) )
I certify,under the pain and en ties ofP�I u that the information on this application is true and complete.
FIRM NAME: .cl �1�/t�Rs•O ie, /
LIC.NO.:
Licensee:�� �Q��,��� �� Signa '�`/
(If applicable, entey.,exempt"in t e licenserp!comber line LIC.NO.:
Address: /'L�tJ ps-g Bus.Tel.No.:—60-3
*Per M.G. c. 147,s. 57-61,security work requires Departrn t of Pubhic Safety"S"License: Alt L cl No
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the Iiability 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: S �Q G7
a -
The Comm.onweizlth of Massachusetts
Department of Dradustruzl_accidents
Office of 1-Mestigations
600 Washington Street
Bostorz, AIA 02111
www.Mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers
Applicant Information
Please Print Legibly
Name'•(Business/Organization/Individual):
Address:
City/swe/Zip:
Phone#:
Are you an employer?Check the appropriate boa:
1.❑ I am a employer with 4. 0 1 am a o Type of project(required):
general contractor and I
?.[ employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
] I am a sole proprietor or partner- listed on the attached sheet 1 7• ❑Remodeling
ship and have no employees These sub-contractors have
working for me in any capacity. workers' comp.insurance. 8• ❑Demolition
ca a.cP t5t•
[No workers' comp. insurance 5. ❑ We are a corporation and its 9. ❑Building addition
required.] officers have exercised their
.I am a home10•7 Electrical additions
3.❑ owner doing all work right of ex
emption per MGL 1 LQ Plumbing,§1
myself: [No workers' comp. C. IS� .
� (4),and we have no repairs or additions
insurance required.] t employees. [No workers' 12•7 Roof repairs
comp.mstl ._ceOther
=-m'2PPIic--ut that cheat's box#1 miSi aiso rYtl cut nc v
ems^^_L`CiQR,3hQ5 We`^— R•o?„'•,.Tr..'Ct)W^a..
Flomeownets who submit this affidavit indicatin-the;,a.e dog^ ,. r=
+Contractors that check• �- rk
..E h min and then hire outside eont_ra o;41st submit a new affidavit indicating such.
this box must attached an additional sheet showia�the
same of the sub-c(Mtt'a--tors and their workers'comp.policy information.
I am an employer that is providing workerscompensation insurance for
information. my employees Below is the policy and job sue
Insurance Company Name:
Policy#or Self-ins.Lic.#:
Expiration Date:
Job Site Address:
Attach a copy of the workers'compensation policy declaration age shov►�City/State/Zip:
1 page ( � 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 certifj under the pains and penalties of perjury thczt the information f maiion provided above is true and correct
Sisnatur�:
Phone#:
O,ffzcial use only. Do not write in this area, to be completed bj,cam,or town ofjiciaL
Cita'or Town:
AermitUcense#
Issuing Authority(circle one):
I. Board of Health 2.Builaine Department 3. Cify/Town Clerk 4.EiectricaI Inspector 5.'lumbin
6. Other b Inspector
Contact Persue:
'hone
Date.l�J'.2.3- 0 3
NORTH
TOWN OF NORTH ANDOVER
!r FO �� 9
PERMIT FOR GAS INSTALLATION
�,SSACMUSESZ
This certifies that . e'l!: . . . . . . . . . . . . . . . . . . . . . . . . . . .
. .. . . . . . . . . . . . . . . . . . .
has permission for gas installation ¢-*. .-?� . . . . . . . . . . . . . . . .
in the buildings of . . . 1 : . . . . .: . ! :.r. . . . . . . . . . . . . . . . . . . . . . . . .
at . . .? ! J<. 1.-. �(. . . . .`� . . . . . . , North Andover, Mass.
Fee. . . . . . . . . Lic. No..! . .�. . . . . . ./.), ��. . . . . . . .
i GAS INSPECTOR
Check# '
4463
t
MASSACHUSETTS.'UNIFORM APPLICATION fiOITfERMtT TO 00 GASFF TING
(Print or Type)
W�M jV�- Mass. Date (O�� 2QPermit
BulldkV:lroo>�lon"� - 7`7 :cJ �� J owr,er"sName 1(kic/Lic,' IJ _ N. Y-dLt(
4 "- (Ao. l�V�`� /Type of 0=*ancY �
Sf��t c,
New ❑ Renovation. ❑ Replacernent�o-' Plant Submitted: Yes❑ No p
a
M Z• a:_ a
a c a e: o a. ~, �.
W j aW. 0 w o- _, s a.
C s ♦' < e' _ = O � W
< o a ta- 44
0 6 W
a S W Z L`. Nr. a W C �2
H !� a J P Z0 ` Id,
y� < W .� < 6 F i•' a O
O C O S
C S O Or
; a a 3 0 C > O a.
sus—BSMT.
BASEMENT
y 1ST FLOOR
ZND FLOOR
3RD FLOOR
4TH FLOOR
STM FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
Installing Company Name- Ap�a�2tr� �l �.b, �. Cho*-amw Certl fcatt.
Address__ 5ti4 (2ca .t Wit- . Q carpomuon.
.. Q Partnership
Business Telephone —rA i- a&7q - _c�s-zt Lg A Fimt/Co.
Name of Ucensed Plumber or Gas Fitter SkLxeh S Aaclr veS^
INSURANCE COVERAGE:
1 have aYecunuttlWARY in ❑suranoe'pOlky or ft Sal equMalent�Whlch meets the mqufremwft of.MGL!CK•142.
If you havve'dadoedaM& *,dlcda*etypesovmge-by docs f the appoopdste.box
A IWAlty insuranoe.pofky n Other:.type-flt lndemnity.❑. Bond ❑
OWNER'S INSURANCE WAfVEW l am-swwo that the llcumse does riot-have• the Insursnoe-coverage requioedby.
Chapter 142 of the-Me= General Laws. and Moat my sigrtahtre-on•thls-pem*-applkation waives.e t requkement
Check one:
&gnatun of-0wner_or-0WWs Agwt Owner❑ Agent O
1 hereby cw*that all of the details and information 1 have submitted(or entered)in above applialkm ant true and aoarrate to.the begot my
knowledge and that d plumbing work and inatauabm pwformsd under the permit issued for this appkabm will be m oomphanoe with d
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Ganem taws.
BY T of License: 10
Tito Plumber %nauuwdf or Gas
City/Town jwnwm
License Number 131 OCD.
BELOW FOR OFFICE USE ONLY
FINAL, INSPECTION SKETCHES PROGRESS INSPECTION
FEE -
NO.
APPLICATION FOR PERMIT TO DO OASPITTINO
s
NAME A TYPE OF BUILDINO
LOCATION OF BUILDING
PLUMBER OR OASPItTER
Lie. 110.
PEIIMIT OIIAMtED
DATE x20^s
, OAS INSPECTOR �
: . spa �w
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
C �ous�
DATE OF PUMPING:( QUANTITY PUMPED l�'z" GALLONS
CESSPOOL: NO YYES SEPTIC TANK: NO YES ✓
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: e T�SlStrtT-
COMMENTS:
CONTENTS TRANSFERRED TO:
qLFOR OFFICE USE ONLY
The Commonwealth of Massachusetts
Permit No.
Department of Public Safety Occupancy&Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 (leave blank)
APPLICATION FOR PERMIT TO .PERFORM ELECTRICAL WORK
All work will be performed in accordance with the Massachusetts General Code.527 CMR 12:00 qQ/
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
City or Town of /VO.PT7f 1'5�/,DOA9;e_ To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below:
Location(Street and Number) 575441 . 10/-Al� N S� AE251"' Map: Lot:
Owner or Tenant �7/C'f /g �/VDU��.L� Zone:
Owner's Address
Is this permit in conjunction with a building permit? Yes❑ No.2heck Approprta e x
Purpose of Building Utility Authorization No.
Existing Service—6�/O Amps Z Z U /_—VO Volts Overhead Underground ❑ No.of Meters
New Service 10C) Amps /ZC] / Z Volts Overhead Underground❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work /�� �f'YI� ��.P///CE ��i4/l/C /N /*a
e a a vc S
No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA
No.of Lighting Fixtures Swimming Pool Above grnd. ❑In-grnd.❑ Generators KVA
No.of Receptacle Outlets No.of Oil Burners No.of Emerg.Lighting Battery Units
No.of Switch Outlets No.of Gas Burners FIRE ALARMS No.of Zones
No.of Ranges No.of Air Cond. Total Tons No.of Detection'and
No.of osa
Dis ls No.of Total Total Initiating Devices
Disposals Heat Pumps Tons KW
No.of Dishwashers Space/Area Heating KW No.of Sounding Devices
No.of Self-Contained
No.of Dryers Heating Devices KW Detection/Sounding Devices
No.of Water Heaters KW No.of Signs No.of Ballasts I Local❑ Muncipal Connection❑ Other
No.of Hydro Massage Tubs No.of Motors Total HP Low Voltage Wiring
OTHER:
INSURANCE COVERAGE:Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy
including Completed Operations Coverage or its substantial equivalent.YES❑NO❑ I have submitted valid proof of same to this
office.YES❑N
OIf you have checked YES,please indicate the type of coverage by checking the appropriate box.
INSURANCE ❑OTHER❑(Please Specify) r7 .E -:;;7 1-11-197
—/f—
(Expiration Date)
Estimated Value ofEll trical Work$
Work to Start Inspection Date Requested:Rough Final
Signed under the penalties of perjury:
FIRM NAME ✓ C LIC.NO. 41I33a
Licensee --J114EV149lV.$ Signature LIC NO.
Address d. L\,/ AZO7 017/ 7CP11J Bus.Tel.No. 52V' 777-_05G22
Alt.Tel.No.
OWNER'S INSURANCE WAIVER:I am aware that the Licensee DOES NOT HAVE the insurance coverage or its substantial
equivalent as required by Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Owner❑ Agent❑ (Please check one)
Telephone No. PERMIT FEE$
(Signature of Owner or Agent)
INSPECTION RECORD
Date Notes — Remarks Inspector
Date.... ..........................
HORTI,
°�t ``°:•�"� TOWN OF NORTH ANDOVER
I = p PERMIT FOR WIRING
�,SSACMUS�
This certifies that ...=:... �-r1
........................:..................................................
has permission to perform ....
wiring in the building of
e /
` .. ..... ,North Andover,Mass.
at. {?.....Y.... cc.. ..........................................
Fee :- /)...0-e'61..
U.. Lic.No, ���n _... ;,:i ..........
..... . .. ...... ....
/ ELECTRICAL INSPECTOR
Check # � �
464;
:'""-. ��a�titGCt't�,•E:�.'Fi► t,f�c3'SS�C13LtSi@1'�t i t7.ticacl'���:*,�v ..---•
�i Ai D0ARrt",e,,f of-Hre services I Permi,-40. -
t
OF FIRE PREVENTION REGULAT:��NS C�xupnct y ane!Etc Cl►ccked
u� (Rev. t l/o- ` leave i>lanic' '
APPUCATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work t,�be perfr)nred in acscrdance wit,the Massaeriusetts Elee nC311 Code( C„5r CMF. 1 Z.OD
^j.A,/—•1"JUT W DVA'or,7T?E 41 L NFORIJA7 YO.9 Ute: � t 3 c7�31"00/
City or Timn of. NA To ilre.CPIs ctor of Wires:
ny,I pis aprfchton the LUUWR&Migneci Sivrs notice cf his or her R-7.060nn to p�erpfo�rm the electrical work dtsctibW below.
i.cnatioo tSrrcet&Nuntbc►;1
Owner r-vr 7'Mant
Chrner'S Address
is thiS permit in con junction Leith a b'tilding permit? Yes ❑ No [ (Check:Appropriate Box) -
Purpose or Building ' Utility Authorization No.
E.isti►tg Senicc- Amps i 194()Voltt Overhead R" Uudgrd❑ No.of hiders
New S0"Of ___ AmPs Voles Overhead❑ Undgrd❑ Am of Meters
_Nauti►cr of Feed n s and imVicity _
LKation and Nature of T''roopowd Elt-Arical Work:
_ Crimtertort ofthe o1lmvin table m 1w waived b litre lis creraiil7rz:.
i
A,&of Recessed FiriuresNo.of CeiL•Susp.(Paddle~Fans iNO.of Trattsfotmers .I�'VA
No.r f Lighting0utletS .To.of Hot Tabs ` Generators KVA
No.of L•igh$ng Fixtures Swimming Fool Ve ❑ - ❑ o.o mergcktcy li ng
,.+ ntd. d. Batter Units
ENo.of Receptacle Outlets No.of Oil Bumers FMALAli1Ks No.of Zoneg E
Ma.of Switches ��ta.of Gas Burners No.o etectioa an
( --__ _ iaitiatin be�►it:es ''
No.of Ranges INN.of Aar Coad. r° lains No.of AlerdagAerlees
No.of-waste Disposers eat mn Tons ,_ - N o.o nta n
t _ Totals: Detection/Atert' Devices
�Nc,.of Dishwasbars, _ SpacelAreaH,eating KW Lncal ❑ ppal ❑ Other
Connec3ion
�No.of Dryen HeatingApplianoes KW SecurltT Systani
u.off`i3`ates No.of Devices or ivalent
ilio.o o.o Tata Vert
+ Hratters KW S� Ballasts f s or Equivalent
Telecommunications Wiring:
�NZo.flydromassaft Bathtubs No.of Motors Total No.of rivgleut
OTUER:
Atthchadditionaidetait il'desired,oras reodmd by flu IntsectororWi -
LNSURANCE COVERAGE- Unless waived by the owner,no permit fer the performance of electrical work may isstkc u.leas
the li<•rir Ee picMdes proof of liability:rrsmance stlCdu&g eompleW operation"covetagc or its sabsbm int etprivLf,01% 'Trite
updersiqsed certifies that such mejW is iti for c,~,and has exhibited proofsame to the permit t3 o ce.
C1�CK ONE: INSUL rrCE aND ❑ MIYER ❑ tSpt ) re o
(Expiran n • )
Estimst A Value of Flecxncal%York: _ 0�' (When retlttit ed by n'•tuuaipai policy.)
to Stara: s lnsfc utions to be togaestcd in accordance wit='s NEC Vale 10,and d son camp'etio:a.
I certify,carder*,,paha and peaa c fR F4ff'ur);Nkat the anon on this aF Trcatian is true and c anpJde:
F>< > hAtiYL: c )LIC.NO.; 1 �71�A
gv
Licensee; `V�} Signature LIC.NO.! 15 r
r-t moi•._i:a'vtQ a eM c r�rpt is the licu3 h er li e. Bus Tel.No.`q (D lu
AAx �/�las: G'l _ �f1r �" `0— 6 1q� --- Alf.Tel.Nc►
U W N E R'S LNSU RAti �R;t WAMIR.: am avrate that the LkienS does no;have U_liabitrty immance covet age normallj
re;gt fired by lave. By rty siguatorebelrw,i hereby waive this regairernent 1 am the;check one)L]mvner ❑cmw_r-b aSent.
�viceu r,'Agent
;i,#;rtature �Telephone leo. FE1Dt4iIT FEE: