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HomeMy WebLinkAboutMiscellaneous - 60 WAVERLY ROAD 4/30/201800 8� D m m m 11361 Date ...... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING thiscertifies that .................................. ........... .......................................................... has permission to perform ............... .................. ................. plumbing in the buildings of ....... .... 7 ............................................................. at ...... )U,:54 , e ,,, / k ...... ...... .............................. .............. North Andover, Mass. Fee.......... j .......... Lic. No. -A.A3 ............................................................................. PLUMBING INSPECTOR Check (b P . dy\— 1 PY61- INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESV NO [11 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLIC OTHER TYPE OF INDEMNITY Q BOND Dff 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 10l 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 in compliance with all Pertin nt ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMELICENSE # SIGNATURE MPK JP 01 CORPORATION �1 # PARTNERSHIP D# 4 LLC D� L COMPANY NAME ADDRESS ° CITY -.----. ___...__...._.I STATE ] ZIP TEL FAX ^�_ i CELLS { EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK l � POWNER TYPE OR PRINT CLEARLY ` CITY MA DATE ( PERMIT # JOBSITE ADDRESS l�pJ�I- _ OWNER'S NAME j ADDRESS f TEL[ ---11FAX OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL RESIDENTIAL] NEW: 0 RENOVATION.)R REPLACEMENT: 0 PLANS SUBMITTED: YES ® N0E]I FIXTURES'l FLOOR- 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/OIL/SAND SYSTEM I -- __.____.1 -__J __ _ I __I ____I __._-.J- f _--__f _ .. 11 IL--( DEDICATED GREASE SYSTEM _._ J DEDICATED GRAY WATER SYSTEM f f _ I E J I j ..__, , i _ __f f DEDICATED WATER RECYCLE SYSTEM DISHWASHER f -- _J . _I ----J ---_ __...._- ----- DRINKING FOUNTAIN _ f ) -_.--_ f .__---_f ._._._f f I _-_---i •-_--; ..__..__.f FOOD DISPOSER 1 -____..._.____ J ._.�i Jif _.!Ef FLOOR/ AREA DRAIN _..._. �_ 1I ._�.._.-_-.._._.__.-__..(f .._.__.___. 7it INTERCEPTOR(INTERIOR) ►..___. _-._ _.._..___.___._____..__._.___ _._._.._ QAKITCHEN SINK _1— --___i ____ LAVATORY ROOF DRAIN SHOWER STALL -_._______�__--..._�._11 __.r._____,_..___�. .J.1 SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATE;{ PIPING f _._ I ----..J _ J J ...-.___ 1 __...___ J -_.-._j f i OTHER _ _� _ I. I _I ____J ' I __- . _I _ ► ......___ __..__i ! —I 5' INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESV NO [11 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLIC OTHER TYPE OF INDEMNITY Q BOND Dff 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 10l 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 in compliance with all Pertin nt ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMELICENSE # SIGNATURE MPK JP 01 CORPORATION �1 # PARTNERSHIP D# 4 LLC D� L COMPANY NAME ADDRESS ° CITY -.----. ___...__...._.I STATE ] ZIP TEL FAX ^�_ i CELLS { EMAIL 5/ W H Oz 0 H v w P-4 w o ❑ z El LU W W O W aLU z a a � 5 C0 aLU uj W W u O z a a � w a � U J a a � z w H 1 z v N z a� a P-4 ' V fl T'he Commonwealth of Massachusetts F Department ofjndustrialACcidents I Congress Street, Suite 100 a.- •3�. d Boston, MA 02114-2017 www.massgov/dia OiM Sy�V Workers' Compensation Insurance Affidavit: Builders/Cont�ractors/Ii lectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Oiganizaiionllndividual): Address: ''�`;� Phone #: ` City/State/Zip' _► � ®CLQ Are you an employer? Cbeck the appropriate box: 1 fl I am a employer with employees (full and/or part-time).* 2�an a sole proprietor or partnership and have no employees working for me in `t any capacity. [No workers' comp. insurance required.] 3.[] lam 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 ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have empioyees and have workers' comp. insurance.t 6.FJ We are a corporation and its. officers have exercised their right of exemption per MGL c. 152 § 1(4) and We have no employees: [No workers' comp. insurance required.] (A Type of project ()required): 7. ❑ Nerai'donstruction 8. rRemodeag 9. Demolition 10 [] Building addition 11.[] Electrical repairs or additions 12x.;12xg Plumbing repairs or additions 13•. [] Ro6f repairs 14.0 Other ----- I I *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit•thQ affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such 'Contractors that check flus 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 -contractors have employees, they must provide their workerscomp. policy number. , X 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. Lic. Expiration Date.- City/State/Zip: Job Site Address: Attach a copy of the woxkers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL e. 152, §25A is a criminal violation punishable by a inie up to $1,500.00 and/or one-year imprisonment, as well statement may be forwarded to the office of Inveestigat ons of the DIA for insurancER and a fine of up to e a day against the violator. A copy o coverage verification. X do here crtify under tlaepains andpenalties fPerjury that the information provided above is t eland correct. \ _ n A .. nate• 4 1 d \T15 - official use only. Do not write in flits area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone N/ 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 be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local Iicensing 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•wh6 has not produced acceptable evidence of compliance with the insurance coverage requuiired." Additionally, MGL chapter 152, §25C(1) 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=contractor(s) name(s), address(es) and phone number(s) along with their certificates) 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 for 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 IndustrialAccidents. Should you have any questions regarding the law or if you are required to obtain a i�6rkers' 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 "fob 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 1-87741ASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia Date.....9/7/ .................. TOWN OF NORTH ANDOVER PERMIT FOR.GAS INSTALLATION' This certifies that .......... ..... L.A.1.4e . ..... ....... .... ..... .... has -permission for gas installation ............ Z.5?1.�)Vel .... in the buildings of ......................... k(A at ...... &.6.) ..... . ........ .. ............ . North Andover, Mass. Fee... Lic. .................................................................... GASINSPECTOR Check# 10170 I 01V FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER__ INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES NO E IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLIO OTHER TYPE INDEMNITY ©( BOND0-1 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 a AGENT 0 SIGNATURE OF OWNER OR AGENT 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 mpliiiance with all Pertinet provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 111 A'71 1a'7l k� PLUMBER-GASFITTER NAME r _ ��-,\ ���LICENSE # SIGNATURE MP�L�. MGF EDI JP © JGF [[] LPGI ® CORPORATION D} # = PARTNERSHIP 0#= LLC E#= COMPANY NAME: ADDRESS ' CITY _ � STATE RjK]ZIP Lt FAX CELL _til EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK TYPE OR PRINT CLEARLY CITYMA DATE PERMIT JOBSITE ADDRESS OWNER'S NAME OWNER ADDRESS _—JI TEI.�— � �FAXI- OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL NEW: Q RENOVATION] REPLACEMENT: 0 PLANS SUBMITTED: YES 0 NO0 APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER -,1 �. . _ ......__ a.I . - - ' - - �� .1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE _ . FRYOLATOR _I --- -_ _� -- I — - -1 ---- FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER__ INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES NO E IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLIO OTHER TYPE INDEMNITY ©( BOND0-1 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 a AGENT 0 SIGNATURE OF OWNER OR AGENT 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 mpliiiance with all Pertinet provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 111 A'71 1a'7l k� PLUMBER-GASFITTER NAME r _ ��-,\ ���LICENSE # SIGNATURE MP�L�. MGF EDI JP © JGF [[] LPGI ® CORPORATION D} # = PARTNERSHIP 0#= LLC E#= COMPANY NAME: ADDRESS ' CITY _ � STATE RjK]ZIP Lt FAX CELL _til EMAIL H O z 0 H u w a w e+O Ela z O W j ❑ � W O w O IL z w W 3: � 4QCO w 5 w o w a w w o a U J F., a a Q � W = w LL °z N z O H U W P-i C7 O V m rAg The Commonwealth of Massachusetts Department of lndustrial Accidents 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 PERMUTING AUTHORITY. - Name (Business/OiganizationAndividual):_ Address: %N k �a,3 City/State/Zip: Ase you an employer? CJ?eck the appropriate box: Phone #: 1. ❑ I am a employer with employees (frill andlor part time).* TrI ain a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] In I am a homeowner doing all work myself [No workers' comp. insurance required] t 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have, workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6.FJ We are a corporation and its, officers have exercised their right of exemption per MGL c. 152, §1(4), andwe have no employees. [No workers' comp. insurance required.] Cw 6 Type of project ()required): 7. ❑ Nevv'constriiction 8. *7tkemodeliiig 9. �uj Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12�Plumbing repairs or additions 11E] Roof repairs 14.n Other. *Arty 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. tContractors that check this iiox must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose, entities have employees. If the sub -contractors have employees, they mustprovide their workers' comp. policy number. I am an employer that is providingworkers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #:. 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 fui8 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 verification. I do here ertify under thepains andpe aloes ofpeijury that the information provided a o�e t v, correct. V Official use only. Do not write in this area, to he completed by city or town offrcia% City or Town: Permit/License Issuing Authority (circle one): i 1.Board of Health 2. Building Department 3. city/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Phone 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 hize, express or implied, oral or written" An employer is deified 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 receivef6k trustee cif 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 be 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 xeg4red." 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 Pleasb fill out the Workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if zrecegsary, supply sub=contractor(s) name(s), address(es) and phone number(s) along with their certificates) 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 for 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 IndustrialAccideri& 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 thai 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-NUSSAFE Fax # 617-727-7749 Revised 02-23-15 wwww.mass.gov/dia ., h. Y#'i�' e$w .. '.4•.s§�.:.: „i •j ,i#:� y a `"rr s s Wi� Date ... .. . J."< #4 .. ..... .................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . ....................................................................... has pennission to perfort'n . ...... wiringin the building of ............... .............................................................. at .................. 1. .......................... I North Andover, Mass. .................................. .................................................. Fee.b .� ......... Lic. No. ELEcTRicAL INSPECTOR C h e c k # � 7:,15, 12683-- u Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked , BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07] (leaveblank 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 ININK OR TYPE ALL INFORMATION) Date: — Vo -le - City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice �of`h�is or her intention to perform the electrical work described below. Location (Street & Number) tn() )1t'y u FCLC-N Zlf�) _ Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building LC4% (��/ t`bMC Utility Authorization No. -� - Existing Service 21)0 Amps 111) /916 Volts Overhead Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity R /0 1 1110 No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: �/�� � � U V MO �- -LOCATE of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans %Transformers No. of Total KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaire Swimming Pool Above ❑ In- rnd. rnd. El IN o meLighting Batter Units No. of Receptacle Outlets , No. of Oil Burners FIItE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. TotTons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Nmber ........ . Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW Spg Local ❑ Municipal E] Other Connection No. of Dryers Heating Appliances KW SecurityNo. Systems:* Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of `vires. Estimated Value of Electrical WorA (When required by municipal policy.) V Work to Start: I - `49 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 M BOND ❑ OTHER ❑ (Specify:) C-EtV epi" Lr A t t,tt y I certify, itnder the sins and penalties of perjury, that the information on this application is true and complete. FIRM NAME:. V C.) u i� Aj_\ E-L..E& Iz - .C: w c LIC. NO.: 2 Licensee: vii �. iw Signature!] 7^ ' - j, ---LIC. NO.: a It{ 6b A- (Ifapplicabl enter "e pt" in the license number line., � Bus. Tel. No.: �� n �rJJ Address: �� -i0 01 0{ � Alt. Tel. No.: a" l Co Z *Per M.G.L c. 147, s. F61, security work requires Yepartment 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. I PERMIT FEE. $ j2�� ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the A permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an K, electrical permit shall be issued to the person, fine or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence". during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Sign re: Date: ROUGH INS CTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: 9-17—IS' —lS' FINAL INPECTION: Pass Failed ❑' Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: p —L /—/I' DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of industrialAecidents I Congress Street, Suite 100 Boston, MA 02114-2017 www massgov/dia Compensation insurance Affidavit: Builders/Contractors/Electricians/Pl4Mbers. TO BE FILED WITH THE FERMUMC— AUTHORITY. — - - -- -"-*-4- , Name (Business/Oigai&atiotAndividual): Address: O City/State/Zip: G'UtJ A- 0 u "S-0 Phone #: I I b� Are yo an employer? Check the appropriate box: 1.7Iram a employer with _employees (full and/or part-time).* 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole ,: proprietors with no lemployees. 5. ❑I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6, QWe are a corporafion and its. officers have exercised their right of exemption per MGL c. 152 § im and We have no employees: [No workers' comp. insurance required] Type of project (required); 7. E] w construction g, emodellhg 9, ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12TO:Plumbing repairs or additions 13°. [i Rbof repairs 14.n Other *Ally applicant that chdcks bbk #l.. 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 tContractors that check this ` must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have a, InvPPc_ If the sub -contractors have employees, they must provide their workers' comp. policy number. X am an employer tlzat is providing workers' compensation insurance for my employees. information. Insurance Company Name:. 1' # r Self -ins Lie. #: Below is thepolley andyob szte Expiration Date: T_ I'9�_ 1(0 po icy o - City/State/Zip: Job Site Address: Attach a copy of the workers' compensation p licy declaration page (showing the policy number and expira ion date). Failure to secure coverage as required under iil enalties?inthe form of aaSSTOP WORK ORDER al violation punishable, nd fine of up to $250.00 a and/or one-year imprisonment, as w25A is ell a p be forwarded to the Office of investigations of the DIA for insurance day against the violator. A copy of this statement may coverage verification. X do hereby certi der tliepains andpenalties ofperjzzry tliat the in provided above is true and correct. 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 Wo, express or implied, oral or written." An employer is defhied 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 receivefor. trustee 6f 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 be6n 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 certificates) 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. to advised that this affidavit may be submitted to the Department of Industrial Accidents for 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 IndustrialAccidenis. 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 t6 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 permithicense applications in any given year, need only`submit one affidavit indicating current policy information (if necessary) anA 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-MASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia M -W . - 4-M- VWW2J-,bbb-JUNALJUl0-, Its =6 ri Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 353000.00 m $ - $ 420.00 Plumbing Fee $ 52.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 52.50 Total fees collected $ 625.00 60 Waverley Road 312-16 on 9/10/2015 Kitchen Remodel A Date ... �,j ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... ..................................................... ............. .......... ... has permission to perform ............................................... 7 wiring in the building of ........ ) .......................................................................... ,/10 -Z) � I at ........................................... .. Ad .................... . Nprth.,lUdover, Mass. Fee�� ............ Lic. No.sm.01,9 .... ....... ......... ELEc-mcAL INSPE=R Check # /71 4 7 3 "'1 TIM C0AW0NWE L7H0FM4SS4CHUSE1TS / Office Use only DEPARTAffl TOFPUXJCSAFETY Permit No. BOARDOFFREPREVEMONRWUL4HONS527CMR12.�07 Occupancy & Fees Checkedr APPLICATTONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 Q e1 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street &-Number) Owner-ei�-t e� Owner's Address Is this permit in conjunction with a building permit: ye ® No Purpose of Building Existing Service Amps / Volts Overhead F1 New Service Amps / Volts Overhead To the Inspector of Wire (Check Appropriate Box) Utility Authorization No. _ Underground No. of Meters Underground No. of Meters Number of Feeders and Ampacity a Location and Nature of Proposed Electrical Work S r`C e e gs rehn a ci P No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground D Eround M No. of Receptacle Outlets No. of Oil Bumers No. of Emergency 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 Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal _ Othe _ No. --)f Dryers Heating Devices KW c Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER - INSURANCE BOND • liy n. •o: VeAtbhiz TnS VaLAr• • XVirafionDale i I I• I 25 Lo r _ license No. v� licer>SeNo OSD I G Bt>smessTe1 No.9PD . l{ Q) r q ,D.q AltTe1No. OWNER'S INSURANCE WAVER; Iam aware that theIimw does not have die msuranceoovetage orits st>Lthategtuvalent astequttodbyMassadRLR�tis Ctnetal Laws and that my sigllahue on this pemut application waives thisregttitt ni�lt (Please check one) Owner ® Agent Telephone No. PERMIT FEE ,Signature ot Uwner or Agent The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name 'v fnP� Location: 2 LOrtvNn Oily � u O R H Phone # 4R.1- UQ I I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Companv name: Address City. Phone # Insurance. Co. Policy # Company name: Address City: Phone #: � Insurance Co. Policy # r� i Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1,5oo.0o and/or one years' imprisonment_as_vwX- as_civ►I_penattiesinsbe.fmmrda_STOP WORK_ORDERand_a fine_of.($1-0-OM)-a day.against_me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. l do hereby certify un a pains rid Wallies of perjury that the information provided above is true a ud correct e� Signature a Date ftan 10 Print name 1A>1911 d L�y l h�, Pbone.AQ Q A.V- q D a Official use only do not write in this area to be completed by city or town official' City or Town Permitticensing ❑ Building Dept ❑Check if immediate response is required ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #.- ❑ Health Department ❑ Other Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ........... This certifies that has permission to perform .... R��. yv� jQ 4 ................. plumbing in the buildings of ...... K!�?41. ................... at P. . �P.A ........... North Andover, Mass. Fee -Lic. NoA 7:T. . PLUMB NG INSPECTOR Check # 5 7 3 0" MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) s*_ NORTH ANDOVER, MASSACHUSETTS Date I _ 2 I/'-- 0 3 Building Location 0 wh911-b;e`y / Owners Name I-% ae Permit # Amount Type of Occupancy New Renovation ® Replacement Plans Submitted Yes No KKT-j'RES / I MM MIN WNI (Print or type) Check one: Certificate :.�� Installing Company Name E, S,LCS/,' /��c,�, Corp. Address El Partner. Business Telephone /— c 0- C --'l i — s' 6 9 El Firm/Co. Name of Licensed Plumber: % o(4- x�.f 0 S, �04-(;F - i� 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 11 Agent El I hereby certify that all of the details and information I have submitted (or entered) in above plication are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit sued for this application will be in compliance with all pertinent provisions of the Masslinsetts StateymbiggC# an pter 142 of the General Laws. IBy: OVER (OFFICE USE ONLY Type of Plumbing License icenseum er Master ❑ Journeyman El Location W A0,e No. Date TOWN OF NORTH ANDOVER 0 4L Certificate of Occupancy $ 3c) .1 Building/Frame Permit Fee $ C" Foundation Permit Fee Other Permit Fee $ TOTAL $ 13c)— Check# ta 2—fo 16 7 /'--' 9 AA AA Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI5, RENOVATE,OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: � Z SIGNATURE: Building Commissioner/1for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: n Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning DiA d Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHENAUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record Z-1(VA4 lo iQ 1414114XIy 4), Name (Print Agress for Service: mgnature Telephone 2.2 Owner of Record: Name Print Address for Service: z' i Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: q'I Not Applicable ❑ icensed Construction Supervisor: 6 -0 License Number Address Signam Telephone Expiration Date .�. 3.2 Registered Home Improvement Not Applicable ❑ fContractor LW Za /( t4 y f Company Name „L Registration Number Address gv-/O( Expiration Date Si ature Telephone T M X z R r -e z M 90 0 Mn ic r M r _r Z^ P1 SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 2506) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check ail a ncable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 62 . - ll & A/ SECTION 6 - ESTIMATED CONSTRUCTION COSTS( Item Estimated Cost (Dollar) to be Completed by permit applicant 1. Building G., -CILb�rJ� (a) Building Permit Fee Multiplier .f 33 3 k. -d 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) I� D 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUR DING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf. in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTT%IONN 7b OWNER/AUTHORIZED AGENT DECLARATION KD0/1/ ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief �tN a e of Own er/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB ST N15 RD SIZE OF FLOOR TIMBERS 1 2 3 SPAN DIN ENSIONS OF SILLS DM ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHM4NEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE U A NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed of in: (Location of Facility) c .. ez Signature of Permit Applicant 17,—/ f— � /Y� W3 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Name Name: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Location: City Phone #— I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity Ea1 am an employer providing workers' compensation for Cny employees working on this job. Comnanv name: WAY 01 Prr city, Phone*q7 -7 dK Q Company Warne: ° /,,j . .'—^ Address. r✓i%rc Phone* Failures to secure coverage as required: under Section 25A or MGL 152 can lead tombs invmWon of criminal penatbes. or. foe up to $1,St)C and/or one years' imprisonment m-weRmA%' 44mmaliesiolboSmn-d-a T9P afiue-d IW -W understand that a copy of this statement may be forwarded to the office of Investigations of the DIA for' I coverage verification. do hereby cerfify under the pabrs and penalties ofperjury that Me Monnatiw provided above is truea Waffect Signature Date Print name Phone - Official use only do not write in this area to be completed by city or town officiar City or Town PemtittLicensi Building Dept [:]Checlr d immediate response is reguked � EiG('ll3inQ Board ❑ Selectman's ice Contact person: Phone #: I Health Departlmeni E] Other C/) m m Cf) 0 m Ns .0 � d CO)CD n MZ vs CL 0. r c im � c d� y a� v '00 0 v CD CD CL _ Q d CD CSD O CD C CD y� avC o cm CD I CA O "0 Z CD O CD O CD C c? A O O Z O RG . mCL 0 H y C7 do m CD c Z ?= H O d LA. CL. T �a'a m CD CD -40 . O O =r m m •� O 7�24 fC �• O = O C y: OR C y - o c'==r*:Lw �c o W m O y CD cc CL. > CA >y•� y lig CL Q - 0 0o a I �i C . ..t y m � coc:f. O O :00 CD ��0 3 COP G s 0 0 d. 51 0 S CD: 9 O d -� 0 n ° G p cn " c° A � n w °c v n ` G o C w � � ° cn o 0 x rD dd 09 y ® 7d O � O ►I'r1 1 O )m c BOARD OF BUILDING REGULATIONS ti License: CONSTRUCTION SUPERVISOR �{ As>=3 3' Number: CS fl49&48 Birthdate: 03/13/1951 E Expires: 03/1312004 Tr. no: 19678 •'� Restricted: 00 RICHARD D ROBERTSON i 640 HAVERHILL ST #2 LAWRENCE, MA 01841 Administrator i