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Home My WebLink AboutMiscellaneous - 55 MILK STREET 4/30/2018 55 MILK STREET 210/059.0-0037-0000.0 Date/. /. f NORTH 1 TOWN OF NORTH ANDOVER o ' PERMIT FOR WIRING CHU This certifies that .L.... I n t � n .k......... .............................. has permission to perform .....&A�Aw ...... YA........ wiring in the building of.... ...................................... at........................... .................................. ,North Andover,Mass. 6 1~ee..................... Lic.No.............. ............y .... .. ............. . . ........ ELEc-mcAL INsPE4RT Check # Commonwealth of Massachusetts Oficial Use Only Department of Fire Services Perm"No. q'-7 L�O BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(1VIEC),527 QvM 12.00 (PLEASE PRINT TV INK OR TYPE ALL INFO TION) Date: //�15 ILI) City or Town of: To the Inspector of Wires: By this application the undersi ed gives not' e of his r her intention to rform the electrical work described below. Location(Street&Number) J/ �� Owner or Tenant e— Telephone No. Owner's Address Is this permit in conjunction with a bgild'pg permit? Yes No ❑ BLDG PERMIT# Purpose of Building 0 �1/ j 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: ZZS Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total. Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency Lighting rnd. rnd. Battery Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of SwitchesNo.of Gas Burners No.of Detection and Initiatin Devices No. of Ranges No.of Air Cond. Tons Total J- q Devices No.of Waste Disposers Heat Pump Number Tons KWtained Totals: in Devices No. of Dishwashers Space/Area Heating KW cipal ❑ Other ction No. of Dryers Heating Appliances KW Security Systems:* No. of Water No.of Devices or Equivalent No.of No.of Heaters KW Si ns Ballasts Data Wiring: No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent Attach additional detail ifdesired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: //-,f )ZI Inspections to be requested in accordance with NEC 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' surance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove a is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I cert fy,under the pains and penalties of perjury,that the informado o th' plicati is true and complete. FIRM NAME: LIC.NO.: Licensee: Signature r/'✓ LIC.NO.: 7 (If applicable, enter "exempt" n t e lic nse num line.), ' Bus.Tel.No.: `R/ ;7 Address: �?N �tyy L Alt.Tel.No.:*Per M.G.L.c.147,s.57-61,security work requires Department of Public SafLicen 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. $ ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR-DOUG SMALL , 1 INSPECTION: Passed— Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: 1. 5 (Inspectors'Signature-no initials) Date L 2.FINA SPECTION: Passed— Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Signature-no 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. The Commonwealth of Massachusetts Department of Industrial,Accidents Office of Investigations 600 Washington Street JV Boston,HA. 021X1 www.mass.gov1dia 'W'orkers' Compensation Insurance Affidavit: Builders/Contractors/JElectricians/Plumbers Applicant Information ) Please Print Legib Name(B.usiness/Organization/Individual): Address: 53 City/State/Zip:�/1>C�'.�, �J�� Cil 23 Phone#: Are yo an employer?Check the appropriate box: Type ofproject(required): 1.❑ am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/orpart-time}. have hired the sub-contractors 2. 1 am a sole proprietor or partner- listed on the attached sheet.r 7. E]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.❑Electrical repairs or additions 3.❑ 1 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.]i employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 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 anew affidavit indicating such. tContractors 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: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip.- Attach 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 Sec ' n 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 4 fine up to$1,500.00 and/or one-year impriso t,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. B ised that a copy of this statement may be forwarded to the Office of In of the DPA for' cc cove verification. I do hereby cern* nW�41andp all,es ofperjury that the information provided above is true and correct. Signature ZZ Date: Phone#: 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 1 : Date�W&.!. . . . . NORTH TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSACHUS� This certifies that . . t`.�� .l?.f'.h c1;� n `r h `� has permission to perform . . . . .P<A'A :1.11(f.. .`. . . . . . . . . . . . . plumbing in the buildings of . L C. S-- . . . . . . . . . . . . . . . . . . . . . . . . . . at . .5. .)". 1.l. .4° . . . . . . . . . . . ....... North Andover, Mass. Fee. !Y?.'Lic. No.. . . . . . . . ... fir. . . .(. . . . . . . . . . . . . . . t PLUMBING INSPECTOR Check # > � t MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: � (►//,/L ,MA. Date: (� �C/ Permit# i Building Location:_ — .�— Owners Name: /' L U C Cc T Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residentia< New:❑ Alteration: Renovation. Replacement)-CIPlans Submitted: Yes❑ No '❑ FIXTURES DEDICATED W2! SYSTEMS z W Y Ou z H Nf O a Uj W- z Y Q {A Q Q H Z W Q C w z W z C H Z 4 m 4A it z FW- `n } Q Y 0 a X Q Q 0 J n Q H 0 Q z W O O W z W VI z U W J 3 Q Y S 0 0 = Z ~ LL 3 Y Q 2 W W W OZS O h W Uj Q 0.Q ut H 0 0 > > O = 0 Q Q Q Q LA W Q Q a m m e o LL Ln 3 3 3 0 a 3 SUB BSMT. BASEMENT 1ST FLOOR 2"D FLOOR 3RD FLOOR 4T"FLOOR 5T"FLOOR 6T"FLOOR 7T"FLOOR BT"FLOOR Check One Only Certificate# wlkInstalling Company Name �YkI/ ❑Corporation Addres / U Cillty/Town:jo�Ml state- �4rcr 2 ❑ Partnership Business Tel: — '� —5 CJ Fax: Firm/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 No❑ If you have checked Yes, please indicate 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 ❑ 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 1 of the General Laws. By Type of License: Title umber ignature of jAensed P umber aster APPROVED OFFICE USE ONLY Vo urneyman License Number: 2