HomeMy WebLinkAboutMiscellaneous - 61 UNION STREET 4/30/2018N
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This certifies that .......
Date .../..�/.1�--.
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
has permission to perform............................................................................................
wiring in the building of............/...............................'..:1......... ..:.�.Z..,.......................
at..................................................
rD
Fee .....
...........'.......... Lic. No.
Check # f
Y
l /7
, North Andover, Mass.
....................................................................................
ELECTRICAL INSPECTOR
Xlfom.moncaea& o f Vaijacf2u M Official Use Only
2,parttmed o f -7ire Semicee Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [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: —41.5115
City or Town ofi NoM ANi')o U f?_ _ To the Inspector of Jlf ices:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) r. I ( )M1()?,f S; E i
Owner or Tenant C-7 F-rsl mC.3 Telephone No.
Owner's Address SAM r_
Is this permit in conjunction with a building permit? Yes ❑✓ No ❑ (Check Appropriate Box)
Purpose of Building jaw+=t4+n1 Li Utility Authorization No.
Existing Service Amps / Volts
New Service ps / Volts
Number of Feeders and Ampacity
Overhead ❑ Undgrd ❑ No. of Meters
Overhead ❑ Undgrd ❑ No. of Meters
Location and Nature of Proposed Electrical Work: 1 1 D t_ D1111 ;
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires 14
No. of Ceil: Susp. (Paddle) Fanso.
of Total
T nsformers KVA
No. of Luminaire Outlets `
No. of Hot Tubs -
Gen ators KVA
No. of Luminaires
n-
Swimming rnd. rnd. E]Batter
o. o mergency ig mg
its
No. of Receptacle Outlets
No. of Oil Burners—
FIRE ALA TS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detecti and
Initiating vices
No. of Rang-------
No. of Air Ctend_ TotaTftl
No. of Alerting De ces
No. of Waste Disposers
p
Heat Pump
Number Tons
KW
No. of Self-Containe
Totals:
Detection/Alerting Dev es
No. of Dishwashers-•----
Space/Area Hea • g
Local ❑ Municipalher
Connection
No. of Dryers -.
Heating Applian �rW
Security Systems:*
No. of Devices or E uivale t
No. of Water
No. of No. of
Data Wiring:
Heate
SBallasts
No. of Devices or Equivalent
No: Hydromassage Bathtubs---
No. of Motore Total uP
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: aS00 • Gc, (When required by municipal policy.)
Work to Start: 61 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 liabili insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cov rage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) Ewa , a-tz;�
I certify, under the pains and penalties of perjury, that the information o thi pplication is true and complete.
FIRM NAME: j,%m W S r L� - LIC. NO.: l g 3 SO to
Licensee: SAMA Signature LIC. NO.:'a,g'33 G C
(If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 9179'7-7-> S'9-S%-
Address:
`33%-Address: 16 L t arf„zry sr- M c 1.» Lr:ruJ M4 01,7W4 Alt. Tel. No.:
*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 a ent.
Owner/Agent �j
Signature Telephone No. PERMIT FEE: $ (/
D
The Commonwealth of Massachusetts
c z Department of IndustrialAccidents
1 Congress Street, Suite 100
r Boston, MA 02114-2017
www.mass gov/dia
1-'orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information /� Please Print Legibly
Name (Business/Organization/individual): lg L.atymrA2.f3C3l4 rz Fl, t_ .
Address: a1raT y S ;
o1q
City/State/Zip:_ ]I^t p,'JL r k --y pJ 044- Phone4:
Are yo n employer? Check the appropriate box: Type of project (required):
1.7 a employer with _employees (full and/or part-time).* 7. ❑ New construction
2. n I am a sole proprietor or partnership and have no employees working for me in 8. [] Remodeling
any capacity. (No workers' comp. insurance required,]
9. El Demolition
3.[:]l am a homeowner doing all work myself [Na workers' comp. insurance required.]'
4.Q I am a homeowner and will be hiring contractors to conduct all work on my property. twill 10 n Building addition
ensure that all contractors either have workers' compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12. [] Plumbing repairs or additions
5.Q I am a general contractor and I have hired the sub -contractors listed on the attached sheet 13. Roof repairs
These sub -contractors have employees and have workers' comp. insurance.
6. Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Q Other
152, 51(4}, and we have no employees. [No workers' comp. insurance required.]
*Any applicant that checks box # I 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 state whether or not those entities have
employees. Ifthe sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Fd s> r= Z / t= i� �8 $ 333 4141
Policy # or Self -ins. Lic. #:_ q% — Expiration Date:�L]/1
Job Site Address:_ 61 U Ni0nl s r- N - Afj,'Jd J r 2 City/State/Zip: vi, -
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 fine up to $1,500.00
and/or one-year imprisontnen 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 c y of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coveraee verification. /
I do hereby eerdfy $f Vr the*ins and penalties of perjury that the information provided above is true and correct
Signature: " / V \ Date: 10115h 5
Phone #: If
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 #:
A -
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 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 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 -contractors) name(s), address(es) and phone number(s) along with their certificate(s) 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
Industrial Accidents. 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. 1n 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 "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
-I 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 www.mass.gov/dia
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E-LECTR] C I ANS
iSStU THE-fot-L-tiWN61 f-EfNSE
AS A R'EG JOURNEYMAN ELECTRICIAN
JAMES J C.ARBONE
16 LIBERTY' ST
�i.
MIDDLETON MA 01949-1802—
28336 E 07/31/16 -39797
Date la.11,5-6. r
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that...................... .........r
has permission to perform ...i ...............
plumbing j'n the buildings of........
at �9 .... l �ll�...........................................
Fee �5 S U.. Lic. No.
Check # 0 j�
.............................................
S/!�.......t ` ! s. ........
.................................................................................
h Andover, Mass.
............................................................................
OLUMBING INSPECTOR
I
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
'
"� ✓
CITY 6_____ _ MA DATE(PERMIT #
JOBSITE ADDRESS Ci VU0 ✓1 II OWNER'S NAME
POWNER
ADDRESS TEL
TYPE OR
OCCUPANCY TYPE COMMERCIAL ® EDUCAT 0 RESIDENTIAL
PRINT
CLEARLY
NEW: �] RENOVATION: REPLACEMENT: _ PLANS SUBMITTED: YES 0 NO
FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7
8 9 10
11 12 13
14
BATHTUB f _ ( E E ! 1 I _ 1 __. ( 1
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM _,_.. ( __Jj,__ _f
DEDICATED GREASE SYSTEM _l � ___
DEDICATED GRAY WATER SYSTEM ( . _ ► __.- _._,.{ _____( j ___ ._. _ _ .__._ f-_____� _1 !
DEDICATED WATER RECYCLE SYSTEM f _._.__..1 .._._..__I .__ _ __._..�
{ _( .__.__ ._...__._( ____ ( -_-I _{ _-_.I
DISHWASHER
DRINKING FOUNTAIN _I 1 .-_._ ..-----_1 _____.. { _-_----�
FOOD DISPOSER f ..-_-. _.(._._ ._-( _f I .--_...� ____.--�--_-_-.- f _ _ _-_f _.... -. I
_ __ ..f -... __1
FLOOR/AREA DRAIN _1 1 __._._f _.__1 (_-__j ____J .__..__i -------!
__-.I _._.-__f
INTERCEPTOR (INTERIOR)
KITCHEN SINK 7 J —. -.- _�I ______1 __._ I _______1 _.__i .__.__ 6 _...._._{ ___._..__I __.__..➢ _._-__� _ ! ___.--�
ROOF DRAIN
JHO
ER STALL
SERVICE / MOP SINK w _ .l i _____f -_._f I ._.._ _f _._ __ 1 ___--__l _ -__I
TOILET
URINALE ...._.__ E __...__� _..._._( ____1 ._.____S _.-_.__---_--._. I _._._.� .___...__I ..____� .___-.J ........
WASHING MACHINE CONNECTION I ` _._..._ _ I ._..__., f .. __..1 _ _ __� - i _-_.._ F77
WATER HEATER ALL TYPES _6 { l L_
WATER PIPING I _I I ..____._I f !
OTHER(.._._..... -(I ----.
..-__.____J--_f(t
--J ----------
INSURANCE COVERAGE:
1 have a current liability insurance policy or its substantial equi ent�which meets the requirements of MGL Ch.142. YE
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE VERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY _2 OTHER TYPE OF INDEMNITY Q BOND -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 _i AGENT
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 accur a to t es of my knowledge
and that all plumbing wor d installations performed under the permit issued for this application will be in c is a wi Pe ' nt ovision of the
Massachusetts Statermbing Code and Chapter 142 of the General Laws.
44 1
PLUMBER'S ME I _!G�rC�2C�� S LICENSE # f� I SIGN RE
MP JP Q CORPORATION n# PARTNERSHIP _i # LL
COMPANY NAME CcGCvL� S v _ ADDRESS
CITY c i -- k1 _ 1 STA - � ZIP G Li Y II TEL
FAX -- -- CELL
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The Commonwealth of Massachusetts
Department ofIndustrialAccidents
.. ~.�; ' 1 Congress Street, Suite 100
Boston, MA. 02114-2017
www mass.gav/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PEgM(TTING AUTHORITY.
Name (Business/OrgaiiizationAudividual):
Address:
City/State/Zip:_
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with V • employees (full and/or part-time)."
2_01 am a sole proprietor or partnership and have no employees working for mein
an ca acity [No workers' comp. insurance required.]
d le -
44 el
e-
44el 06 1 'C (-j k,
_6S
. Phone #: �� % ' 7�. �' Z k
J P
3.❑ lam 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
6. ❑ 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.]
Type of project (required):
7. ❑ NdVdonstr&tion
8. [] Remodeling
9, ❑ Demolition
10 [] Building addition
11.0 Electrical repairs or additions
12. Q Plumbing repairs or additions
13. [] Roof repairs
14. C] Other
*Any applicant that check's box 41 must almsaiiill�oui�ey section doing below
ll work and then hire outside cm ntrac oPensa ors must submit a new affidavit indicating such
Homeowners who submit this affidavi g
#Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have
Tffl,P soli -contractors have employees, they must provide their workers' comp. policy number.
lam an employer that is providingworkers' compensation insurance for my employees.
information. l ^ J � 7
insurance Company Name:
—u —
Below is thepolicy andjob site
Expiration Date:
Policy # or Self -ins. Lic. #: -�/
City/State/Zip: ef
Job Site Address: C s QCs �� the olic number and expiration date).
Attach a copy of the -workers' compensation policy declaration page (showing p y
on
by a fiftb up to $1,500-00
Failure to secure coverage as required under MGL penalties in §25A is a form ofaSnal iOlati
WORI ORDER and fine of to $250.00 a
and/or one-year imprisonment, as well as i p
day against the violator. A copy of this statement may be forwarded to the Office of Tnvestigdtions of the DTA for insurance
coverage verification.
X do hereby ce y und�hepa' radpan=lfies ofperjury that the information provided abov is true and correct.
M
Official use only. Do not write in this area, to be completed by city or town official.
permit/License #
City or Town:
Issuing Authority (circle one): '
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 they employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of We,
express or implied, oral or written."
An employer is defuied as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enierpri'se, and including the legal representatives of a deceased employer, or the
receiv&4 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 who has not produced -acceptable evidence of compliance with the insurance coverage r'equtred."
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
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 Viability 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
Industrial Accidents. 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 "rob 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 www.mass.gov/dia
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
21 �050.00
m
$ -
$
252.60
Plumbing Fee
$
31.58
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
31.58
Total fees collected
$
415.75
61 Union Street
478-2016 on 10/14/2015
Kitchen Remodel
Date ...... ... ...... .. q— . / . 0 ..
........ ...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .....:.............fit ?:(,) ................................... ....
has permission to perform .......... . .....................
w .....
wiring in the building of ......
......
......... ............................................
at .. C-
...
.. .......... ............... . North Andover, Mass.
Fee .... 2S..�G.. Lic. No32?1.9 7 ............. ......
ELECTRICAL INSPECTOR
Check # ?6
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This certifies that
Date.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
................
has permission to perform .. 01. (.. A ! h r 1. ... PPj .C, !./. I ........
plumbing in the buildings of ..0 C .....................
at .... 7........ ... North Andover, Mass.
Fee. ...a.,1....Lic. No..,l.I?%<J' ...... ��,f.4�.�
p PLUMBING INSPEC OR
Check #
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town: MA. Date: - - ` Permit# �J y
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Building Location: (0/ a/V %Q'v �� Owners Name: / 1, • &42's
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
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New: ❑ Alteration: ❑ Renovation: ❑ Replacement: 2--' Plans Submitted: Yes ❑ No ❑
r1VT1 iocc
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 Yes VNo ❑
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
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted for 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 issues Tor ims appucation will uc ill�.,ra.,.� ..........
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 Yes VNo ❑
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
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted for 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 issues Tor ims appucation will uc ill�.,ra.,.� ..........
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By
Title _
Citylrown
APPROVI
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USE ONL
'Type of License:
Rber..y,......ti�•...., �f ._
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[]journey License Number:
man
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Date .....
N&
TOWN OF NORTH ANDOVER
VIC A
PERMIT FOR WIRING
This certifies that ......... 4.1)7- S�&,?, ........
.............................. nx .....
has permission to perform ............ 5.,vs D Le.t C-7. ........................
wiring in the building of ................ cellvc--
( 8 t)A)/ 6 PL'; ..... I ............................................................
at ................................................. ,
......................... . North Andover, Mass.
FeeL/5 ... . .... Lic. No .............. .................
S�666 ELECTRICAL INSPECTOR
Check # (:2 7.3
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BOARD,OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. c
Occupancy and Fee Checked
(Rev. 1/071 leave blank)
APPLICATION .FOR PERMIT TO PERFORM ELECTRICAL WORK
T All woe(clto be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PL,FAS.E FRLVT Pi INK OR TYPE r flVF RW TION) Date:
G!y or Town of: ��/!?� lib-' To the Inspector o Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number)
Owner orTenant i, e5/,
Telephone No. f7;rr—,t �'J- C/lF3
Owner's Address
Is this permit in conjunction with a buildin permit? Yes El No n (Check Appropriate Box)
Purpose of Building
Existing Service Amps _ 1 _ Vhlts
New Service Amps / _Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical, Work, -
Utility Authorization No.
Overhead ❑ Undgrd ❑
Overhead ❑ Undgrd ❑
L) L I a.�- ► a
No. of Meters
No. of Meters
� Gu. r• t o r• • t rc �.a : r>7
S Ls -rem
rmmniet;nn ofthe tollowinQ table may be waived by the Inspector of Wires.
_
No. of Recessed Luminaires
_ __..-- ---- - -• - -
No. of Ceil: Susp. (Paddle) Fats
o. of � ora
Transformers KVA
"--KVA
No. of Ii(et'fubs
Generators
No. of Luminaire Outlets
No. of Luminaires
—` A ove ,n- ❑
Swimming Pool rnd. �rnd.
No.oTEraergencyLig ting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches i
No. of Gas Burners
17T. o Detection an
. ;i•iating Devices
No. of Ranges
No. of Air Cond. TotalTonsNo.
of Alerting Devices 3
No. of Waste Disposers
eat amp
Totals:
um
o. o Self -Contained
Detection/Alertin Devices
Space/Area Heating KW
unicipat Other
Local ❑ NConnectior. ❑
No. of Dishwashers
Heating Appliances Kyr
ecurity ystems:*
No. of Devices or Equivalent AS
No. of Dryers.
Kf WaterW
No. o. oe
o. of o. o
Ballastq
Data Wiring:
No. of Devices cr E uiv 1=nt
ters
Si ns
e ecommunicattons irrng:
No. Hydromassage Bathtubs NoMotors Total HP No. of Devices'or Equivalent
OTHER: r 97 a 3 S
--- ,ra,,,;t ;rao.;.va nr ne _n";rPd by the Inesoeetor of Wires.
Estima ed Value 9Tf Electrical WoInspection
/at e C20 (When required by. municital policy.)
Wurk to Start: s 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 insurancf including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is iii force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ® coND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perju ,v, that the information on this application is t.,-ue and complete. S3 3
FIRM NAME: ScrVLeRs LIC. NO.-
_ Signature__ LIC. NO.:-
Licensee:
UJ.: —�
Licensee: �( K
ll pp i _ �H a3o�9 Bus. Tel. No.:
1 a lieable, enter j e e p[' thellieen_.. mm� er 1� _ t / //tom AIL Tel. No.:
Address: � L �7 � �"' l y�U
*Per M.G.L. c. 147, s. 57-6 t; security work requires Department of Public Safety "S" License: Lic. No. S cC G l9
OWNER'S INSURANCE WAIVER: 1 an 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 aacnt.
Owner/AgentTelephone No. PERMIT FEE. S K�
Signature --
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Department of Public Health & Department of Labor
NOTIFICATION OF DELEADING WORK
All sections of this form must be completed in order to con
the notification requirements of M.G.L. C. 111§197.
454 CMR 22.00 and 105 CMR 460.000, as most recently an
Contractor performing project Aulson Roofing, Inc
Lead Paint Inspector Stanley Bagrowski
ADDRESS OF PROJECT:
RECEIVED
wit]i f: tl � i� 1,012
AWN OF NORTH ANDOVER
HEALTH DEPARTMENT
License # DC001523 Exp, Date 03/28/12
Date of Inspection 11/29/11 License # 1-3572 Exp. Date
Street Address 19 Merrimack St., No. Andover Apt. Number
City North Andover, MA Zip 01845
Property Owner Robert Gesing['—Add' ress 61-U4i6'ft-Strejet, No: -Andover 01845
Telephone Number (978) 683-3230
Deleading Method:E]Wet/Dry Scraping ❑ Heat Gun Liquid Encapsulant
[]Demolition ❑ Caustics Replacement
QCovering Other
If "Other'' selected, please explain
Check one: Dwelling is multi -family Single-family Other
Start Date 02/01/12 Completion Date 02/03/12
When will work be done: AM 7 PM 4 (Specify times on site) Weekends? NO
Project Supervisor Name Gary Eap License # DS003310 Exp. Date 08/29/12
Worker's Compensation Policy Number WC490OP41A Carrier Ace American
In case of emergency contact Scott Aulson Tel. #9( 78 ) 423-3472
(Contractor's Representative)
DELEADING CONTRACTOR
The undersigned hereby states, under the pains and penalties of perjury, that he/she has read and understood the Commonwealth of
Massachusetts Deleading Regulations, 454 CMR 22.00, and the Lead Poisoning Prevention and Control Regulation% 105 CMR 460.000, and
that the information contained in this notification is true and correct to the best is/her kpowledg"d bf * E
Date January 23, 2012 Signed
Company Name AULSON ROOFING, INC.
Address 49 DANTON DRIVE, METHUEN, MA 01844
Telephone Number (978) 9754500
OVER4
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Date .......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
r c'
This certifies that ......... T ........ ...............— ............ (....j
........................
r—� le, (,/
has permission to perform ..........,r ........................ e,
. ......................................
-siring in the building of ...... I
-Y .................................................
at ........... ......... 5.t ... ................. orth Andover,
r '- 0 ... Lic. NqA7
Fee .'3.L: .............
Check # V-3 7 >'kEiCTRiICAL INSP9CTOR
ConLiwnweahk o`///amac/tlmaj
ccc
BOARD OF FIRE PREVENTION REGULATIONS
For Office Use Only
(Rev.
Permitt Number:
Occupancy & Fee
(ALL WORK TO BE PERFORMED Wmi THE MASSACHUSETTS ELECTRICAL CODE 527 CMR 1
City or Town of: AJ0- 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 & Num
Owner or T
Owner's Address:
Is this permit in conjunction with a Building Permit? Yes
Purpose of Building:
Existing Service:�Amps /10 / V48 Volts
New Service: 16 12,0 /_Volts
Number of Feeders and Ampacity:
Location and Nature of Proposed Electrical Work:
Utility
S[h
I No V (Check Appropriate Box)
Authorizati;��Underground.0
M d
Overhead # of Meters
Overhead iJ' Underground.❑ # of Meters:_
No. of Recessed Fixtures
No. of Ceil.-Susp. (Paddle) Fans
No. of Transformers Total KVA
No. Of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Swimming Pool: Above ground o in Ground o
# of Emergency Lighting Battery Units
No. of Receptacle Outlets
No. of Oil Burners
Fire Alarms # of Zones
# of Detection & Initiating Devices
# of Sounding Devices:
# of Self Contained
Detection/Sounding Devices
Local ❑ Municipal Connection a Other ❑
No. of Switches
No. of Gas Burners
;Io. of Ranges
No. of Air Conditioners -C•TAL TONS:
No. of Waste Disposals
Heat Pump Totals:
Number: TONS: KW:
Security Systems:
No. of Devices or Equivalent
No. of Dishwashers
Space /Area Heating: KW
Data Wiring, No. of Devices or Equivalent:
No. of Dryers
Heating Appliances KW
Telecommunications Wiring: No of Devices or
Equivalent:
No. of Water Heaters KW
No. of Signs: # of Ballasts:
OTHER;
# of Hydro Massage Tubs
No. of Motors Total HP
INSURANCE COVERAGE: Unless waived by the owner, no pe it for the performance of electrical work may issue unless the licensee provides proof of liability insurance
including 'completed operation' coverage or its substantial a walent. The undersigned certifies that such coverage is in forces and has xhibited pMTfsato the permit
issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ Please specify:
Estimated Value of Electrical Work $ —�� (When required by municipal policy)
Work to Start: Inspections to be requested in accordan with MEC Rule 1/and upon completion.
Ice , /nder the pains and penalties of perjury, that the Information on this application is true and complete. a C}
Firm Name: !� L L %C / e/ C / D ���_ LIC. #
Licensee: S • /`7 1S/1 JT Signature: LE' LIC. #
�i
(if applicable, enter " em�pt" Iii the Il /nse numb r line) G
Address: .`-b �y ��CKE�I/��a /� e� //� •�7/�UL1��� /l�� U��C%J Bus. Tel. # �03-� Alt. Tei. #
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 c OR Agent o
Signature of Owner/Agent: Telephone # PERMIT FEE: S (s
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..... fiV7 . ....................................................................
has permission to perform ...........................................
wiring in the building of .... . .
........... . ..
......................................................
at ... ............ ............... North Andover, Mass.
Fee..................... Lic. No..,........... ..........................
ELECTRIC. INSPECTOR
Check # C16 71� 41k
Commonwealth of Massac
Department of Fire Se
o
BOARD OF FIRE PREVENTION REGU
husettS Official Use Only
rvic s Permit No. �S.N�
�� �r✓
Occupancy and Fee Checked
LATI NS [Rev. 9/051 (leave blank)
APPLICATION FOR PERMIT TO RFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code ('NIEC). 527 C`,IR 12.00
(PLEASE PRINT IN INK OR TY LL LVFO LM TION) Date: r%—cl) /D
City or Town of: � 1�47
f� 1i� To the Inspector of Wires:
By this application the undersigned gives nod c2 of his or he�tenrton to perform the electrical work described below.
Location (Street ,*-Nmltber)
Owner or Tenant
Owner's Address
Telephone N
Is this permit in conjunction with a building permit? Yes ❑ NoLie—
(Check Appropriate Box)
Purpose of Building
Utility Adthorization No.
Existing Service Amps 11Volts 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 of the following table may be waived by the Inspector of G , res.
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
Above In-
Swimming Pool arnd. El grnd.
Emergency tg ting
Battery Units
No. of Receptacle Outlets
I
No. of Oil Burners
FIRE ALARMS No. of Zones
No. of Detection ano
No. of Switches
INo. of Gas Burners
Initiating Devices
No. of Ranges
INo. of Air Cond. TotaTonal
No. of Alerting Devices
Heat Pum
Number
Tons
KW
No. of Self -Contained
No. of Waste Disposers
p
Totals:
.....
Detection/Alerting Devices
No. of Dishwashers
(Space/Area Heating KW
Local ❑ Municipal El Connection II
Connection
No. of Drvers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of WaterKW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of'Devices or Equivalent
No. Hvdromassage Bathtubs I.No
of Motors Total HP
'
Telecommunications Vlirinr;:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of 6t%fres.
Estimated Value of Electric I Work: (When required by municipal policy.)
Work to Start: 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 of perjury, that the information on this application is true and complete.
FIRM NAME: ADT Security Services. Inc. LIC. NO.: 1533 C
,'
Licensee: C 4 ,� 1��5 t Signature LIC. NO.: 3gr(�-6 L
(If applicable, enter "exempt " in the license number line.) Bus. Tel. No.: 603-594-5900
Address: 18 Clinton Drive Hollis N.H. 03049 Alt. Tel. No.: 603-594-5930
*Security System Contractor License required for this work; if applicable, enter the license number here: o G'
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 — PERMIT FEE: S �, (%�
Signature Telephone No.