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HomeMy WebLinkAboutMiscellaneous - 65 SPRING HILL ROAD 4/30/2018 / SPRING HILL ROAD - 210//107.A-0242-0000.0 Date TOWN OF NORTH ANDOVER ,` 32, �a,r .., •�OCL � ° p PERMIT FOR PL.U'MBING ,SSACMus� This certifies that . .'. `. r / Ga .--l . . . . . . . . . . . . . has permission to perform . . r Gt '. . . .. plumbing in the buildings of . . �1 f�L r. at . . . . . . . . . . . . . . . . . . . . . . . . . . . ., North Andover, Mass. Feet . . . . .Lic. No.. . / . . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check 7593 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING t (Print or Type) l'`' - ll�Li��f7 hLr� Udr , Mass. Date 7L� 49-002ZPermit# LT=�- 1 r Z., ,_" Building Location S2 J _ Owner's Name hP /SFr �1 c�l�J/P Type of Occupancy New ❑ Renovation ❑ Replacement Plans Submitted Yes ❑ No ❑ FEATURES z ? P I m cn m 0 Z zz > w ~ Y J v7 Q U < rn O cc M z cnz w F¢- w a: = ¢ cn a o Z z Z ° � O Fn tL .u7 U) a: U v7 a ¢ x U o� m ro W } g rw 0 Z Q cn O 2 n Q O v Z UJ ¢ ¢ LLI J Z Q J W = Q = i a Z Y O z z W tW- O v i Q IF- Q Q 07 cn Q ¢ 0 Q ¢ a oC >a O ¢ ►- > Y J m (n J M F- W LL 0 ¢ > tY m O i SUB-BSMT. BASEMENT v 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name C j2 Check one: Certificate Address dam( )' Corporation ❑ Partnership Business Telephone �7fz—)_ ❑ Firm/Co. Name of Licensed Plumber E� Afe o INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. Yes X No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNERS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations pe ormed under the permit issued for this application will be in compliance with all pertinent provisions of the_Jotassachuset lumbing Code and Chapter 142 of the General Laws. By Signature oil Lice um Title Type of Li en : Mast ❑ Journeyman ❑ City/Town License N tuber APPROVFn OFFICF I tSF ONI Y1 Date. d ...... F NOR7H a� TOWN OF NORTH ANDOVER • - PERMIT FOR GAS IN_ ALLATION . y RCHUSEtt This certifies that . . . .`. . . . :. . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . .A45�t?`r?�. . . . . . . . . in the buildings of ".4 . . . .. . ... . . . . . . . . . . . . . . . . at .a �!l.�h� !'?��. � •. . . . . ., North Andover, Mass. Fee,.�. .--�-. . Lic. No.///6-t= . . . . . . . . . . . . . . . . . . . . . . .X). q (�— GAS INSPECTOR Check 6257 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GASFITTING _ (Print or Type) •s ZICI -Pr ,Mass. Date S �'14eRQ0zPermit# Building Location -S�p/i n u /y�� Owner's Name C9(4_/'C_ ✓kms _r/� nor,�P/�r'P Type of Occupancy New ❑ Renovation ❑ Replacement Plans Submitted Yes ❑ No ❑ m m w vi U Z Ir v7 O w m w O Uo m � 2 = m Cc Q O w Q c[ m o = O z w m cn �- w w 0 0_ w m w Q = z H- � tc > a U) m m 0 U w vi w Q 2 O0 p = rn 0 F- Z J f- Z W w > u_ W J w z Q w Q m )_ W m z O z O m = w > oC w Z a o_ < Q O O w E o w F- = Of C7 2 u_ S 0 J U 2 > 0 o_ W O SUB-BS MT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR AAAA //�� //�� Installing Company Nam +e 13-A/. if ;13oe' O �s�r Check one: Certificate Address �/7 Corporation �h r/�?'/Q�y/-/0-,-0/; �� ©��l�J ❑ Partnership Business Telephone / !d` J��`�r��� ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter � �� 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. A liability insurance policy Other type of indemnity C Bond ❑ OWNERS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement. Check one: Si nature of Owner or Owner's Agent Owner El Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts Sta;4zw 42 of the General Laws. By T pe of License Plumber Title iGasfitter Signatur ofL' ensed Plumber or Gas Fitter Mter C* fTown Journeyman License Ndmber VAPPROVED OFFICE USE ONLY) Date./7/ . . . ...... .. 40R TOWN OF NORTH ANDOVER • - + PERMIT FOR GAS INSTALLATI s + 9 SACMUSE�ty This certifies that .; !!��!� ,�. . . !� �!.�� . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . . . . . . . in the buildings of . . .814;'11. . . . . . . . . . . . . . . . . . . . . . at . . . .�,:�. . _,'. n) .h, `�( . . � �. . . . . . , North Andover, Mass. Lic. No.. .�a5c3 ::.r�?'1. 1f! '> ... . . . . . . . . %GAS INSPECTOR Check# / 5655 MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FI'I'I C j (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations (< S.,n Y/a - �i A04 Permit# Amount$ Owner's Name ' New 1.�I' Renovation ❑ Replacement ❑ Plans Submitted ❑ Ij U W vi a � a G °� F o o o z N • xU d z H a x >W CIO d -It WQ z c w o z U o o 3 A a U :y SUB -BASEM ENT B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7 T H . F L O O R 8TH . FLOOR (Print or type) �/ Check on • Certificate Installing Company Name � , Aw/ s L..J � Coco . nn Address Partner. 2119 BusinessTelephone Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check o I have a current liability Insurance policy or it's substantial equivalent. Yes No❑ If you have checked yes, please Indic he type coverage by checking the appropriate box. 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 Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State s Code and Chapter 142 of the General Laws. BY: gnature of Licensed Plumber Or Gas Fitter Title Plumber City/Town G -Fitter =77Number Taster APPR V O ED(OFFICE USE ONLY) Journeyman Date. .1,711 �. . HORT" / o�,, •� ,.'�o TOWN OF NORTH ANDOVER ° AMENp ERMIT FOR UMBING ,SSACMUS� This certifies that 4 �' . .fir.. . . . . . . . . . . . . • • • • • • has permission to perform . . . . .. . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . ....> , . . . . .. . . . . . . . . . . . . . . at . . . . . . . . , r North Andover, Mass. Fee .ft . .`. . .Lic. No.. �? `/�.r? . l�l.l.s�.I. . . . . . . . . . PLUMBING INSPECTOR Check !/ 3 M 7026 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Building Location Date (ls Owners Name Permit# ,(�_s,' Amount Type of Occu anc /►.� New ❑ Renovation Replacementff Plans Submitted Yes ❑ No FIXTURES Q U x a r r (0 a v w a 3 z w z A o > d z o 3 � A 3 A Q o ff >a��v>avr t IE T 4MHBM MFL" 6M FL" 7M Hi" sM FU)CR (Print or type) l / Check one: Installing.Company Name �j v ^ _or— Certificate Address / Partner. /� 7P El usiness Telephone 4 IC E] Firm/Co. Name of Licensed Plumber: — Insurance Coveraee: Indicate the pe of insurance coverage by checking theappropriate box: Liability insurance policy Other type of indemnity E] 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 13 Agent ❑ I hereby certify that all of the details and information 1 have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachuse State Plumbi e d Chapter 142 of the General haws. By. Lire of License mer Title ype of Plumbing License City/TownH71 -, Z um er Master Journeyman ❑ APPROVED;OFFICE USE ONLY Date. . ?. .... . . . . o' "aRT:��, TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING � . ,SSACMUS� This certifies that . ..�. .) . . � `f. . .. . . has permission to perform . . . . ./. . . pWmbing in the buildings of �i9.N S . . . . . . . . . . . . . . . . . . . . . . . . . . at. . . . . .�5' 5 P Pt 7 fG`. .6 k-()Vr.4PO. N0 rth.A dover, Mass. Fee. .2. .!.Lic. No.J t q.a. PLUMBING INSPECTOR Check # { U 5617 r 'MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING tPrint or Type) // OUd R4dakG0 Mass. Date lv &Vj Permit # j - Building Location' Sn� n (a.,ar.a gens Name- 5,1hd.s i- Type of Occupancy New Q Renovation ❑ Replacement Plans Submitted: Yes O No O FIXTURES z Z Y < « • t--' (n N O Z r W W W . W le J rA U ~ N O ¢ ¢ . 0 Z W < WZ 0 Z_ N a 0 J N (0 q x Q < W to Z C nl O < 6 < 3 x Q Z iL m N W p < df x OC a ¢ C W ¢ W O M ¢ < ¢ W F V < S d Z 3e d0 r Z < W W 3e W Z > F O D N �" Z O 0 to _ .W O Cj 2 < F- < < x m < < 0 < J J < ¢ ¢ ¢ < O < I-- 1-, - 1- q U. C O O < ; ¢ m O Sua--esMT. BASEMENT IST FLOOR 2ND FLOOR 3RDFLOOR ATN FLOOR STN FLOOR 6TH FLOOR 7TH FLOOR $TH FLOOR installing Co fmpany ame r•I J- fes- PA til,6 I'll Check one:. Certificate Address__ f fo l nr S S S O Corporation j3-1,JQ'r �� 111.1 D/S-1-4 Q-Fra Business Telephone 7-1 �'7f�- 76 O . Name of licensed Plumber V' Ql INSURANCE COVERAGE: I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 0- No O It you have checked yes, please indlcate the type coverage by checking the appropriate box. A liability Insurance policy 01'00`� Other type of indemnity O Bond O OWNED-S INSURANCE WAIVER: 1 am aware that the licensee does not have the insurance coverage required by Chapter,142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner O Agent O Sr9nature of timer or Owner's bent I hereby certify that all of the details and inlorrnat2nt (or enter in plication are true and accur a to a best of my knowledge and that all plumbing work and installthe I this application Zince with all pertinent provisions of the Massachusetts State Pa and t r 14 of ral laws. BY TUe Licensed ben Type of License:Master Journe O APPPOWI GtyRown (UFFIZENL license Number FF Date....7—..//—,-)6... vfN°oTM f 3r°.t�``- 4, IL TOWN OF NORTH ANDOVER I°- A PERMIT FOR WIRING -o,,,;o-�`� �,S rACNUS� This certifies that ......�!............� ........................� .................. has permission to perform ........../1 —f..I '<,—, ?. ..................................... wiring in the building of...............&A5.�................................................ s��c�+1ct..l !.�4..�....................... .North Andover,Mass. Fee...,V.'_'.. Lic.No ..a?..,7� e. .......... ..A !..... e ELECTRICAL INSPECTOR A -Check # 3 0 6 7 .� Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. 7?i UV5 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 C R 1200 (PLEASE PRINT IN INK OR TYPE, 4LL INFPRMATION) Date: 7111106 City or Town of: /ub. Afjo,)cf- To the Inspector of fres: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant S Telephone No. Owner's Address Sov Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 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: era Completion of the following table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans o.of Tota Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA w► No.of Luminaires 9 Swimming Pool Above ❑ In ❑ o.o Units cy Lighting rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMSNo.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices Total No.of Ranges l No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pum Number Tons KW o. oSelf-Contained Totals Detection/Alerting Devices No.of Dishwashers l Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.o No.o Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent r OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. .4. Estimated Value of le trical Work: (When required by municipal policy.) Work to Start: 7/D 06 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO RAGE: 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: INSURANCELE�' BOND ❑ OTHER ❑ (Specify:) I certi under the pains andTu enalties o er'u that the information fy, � � r-- _f p ,l zy, f tron on this application is true and complete. FIRM NAME: /I ►ow c C -"C LIC. NO.: Licensee: Aotjuc Signature%-,-� s-A- LIC. NO.: 33,6,20E (If applicable, enter "exempt" "n he license hum er line.) Bus.Tel. No.:&J-9,37-SP-15 Address: / 0-.)/ ��e /.Of -d zz .o(/ AIt.Te1.No.:p7e-,2&P67,P/-cult *Security System Contractor License required for this work; if applicable,enter the license number here: 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. $ Signature Telephone No. 7 - 12 - c4 w CIO ok ti Bldg. ZBA Con/Com , Health Fire Chief Police Chief Town Clerk DPW/Engineers Surrounding Towns Planning LEGAL NOTICE NORTH ANDOVER PLANNING BOARD In accordance with the provisions of Chapter 41, Section 81T and 81-U, M.G.L., the North Andover Planning Board will hold a Public Hearing as follows: Purpose of Public Hearing: Application for approval of a proposed 3 lot definitive subdivision, leaving existing house on existing lot, two new lots and new roadway within the R-2 zoning district. Address of Premises Affected Kelsey Lane, North Andover, MA located off Molly Towne Road Assessor Map and Lot: Map 107A, Parcel 234 Description of Premises: The 2 new parcels are bounded off Molly Town Road and off Harold Parker State Forest. Public Hearing Date and Time: Tuesday, July 21, 2009 7:00 PM: Applicant: William & Lynne Gillen, 54/�pring Hill Road, North Andover, MA 01845 Location of Public Hearing: 120 Main Street, North Andover, MA top floor conference room. Information Available: A copy of the plan and application is on file in the Planning office at 1600 Osgood Street, Bldg. 20, Suite 2-36, North Andover, MA, and maybe inspected Monday through Friday 8:30 a.m. to 4:30 p.m. Any person interested or wishing to be heard on the proposed plan should appear at the time and place designated above. �8 F John Simons, Chairman North Andover Planning Board JUL b- 2009 i - - O-ARD-OF APPEP� NORTH ANDOVER PLANNING BOARD IN ACCORDANCE WITH THE NORTH ANDOVER PLANNING BOARD In accordance with the Provisions of Chapter 41, Section 81T and 81-U, M.G.L., the North Andover Planning Board will hold a Public Hearing as follows: Purpose of Public Hearing: Application for approval of a proposed 3 lot definitive subdivision, leaving existing house on existing lot, two new lots and new roadway within the R-2 zoning district. Address of Premises Affected: Kelsey Lane, North Andover, MA located off Molly Towne Road Assessor Map and Lot: Map 107A, Parcel 234 Description of Premises: The 2 new parcels are bounded off Molly Town Road and off Harold Parker State Forest. Public Hearing Date and Time: Tuesday, July 21, 2009 @ 7:00 PM. Applicant: William & Lynne Gillen, 54 Spring Hill Road, North Andover, MA 01845 Location of Public Hearing: 120 Main Street, North Andover, MA top floor conference room. Information Available: A copy of the plan and application is on file in the Planning office at 1600 Osgood Street, Bldg. 20, Suite 2 36, North Andover, MA, and may be .m. Any person interested or wishing to be heard on the proposed plan should inspected Monday through Friday 8:30 a.m. to 4:30 p appear at the time and place designated above.John Simons, Chairman North Andover Planning Board ET 6/30, 7/7/09 Appeared in: Eagie-Tribune on Tuesday, 06/30/2009 ���`� ( � 69 Date.../...... ..... ........ ,�ORTI{ ° TOWN OF NORTH ANDOVER L p PERMIT FOR WIRING �,SSACH / Thiscertifies that ................................................. ......................................... has permission to perform .............. S.`. .. .......nd..M.... wiring in the building of 4Z,0. �"/ C.O'.r 4 .........................r................ ...... at..�� ......f,�r:c.j.��..1�... ..... ...-:..... ........North Ando ,Mas . Fee.....�.�... ......... LiC.N�Z/`.A1`�`���.... .��t,�''�...C.,...... .. ............. ... ELECTRICAL IeI LECTOR Check N 3.s X2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the 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 electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.O..I_.c.143 �3L. Permits shall-be limited as to the time ofongoing 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 entitystated 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 puipose by establishing an automatic four-year extension to certain permits and licenses conceming 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. ule 8—Permit/Date Closed: / L- Note:Reapply for new permi 3-- 0 Permit Extension Act—Permit/Date_Closed: Commonwealth of MassachusettsFOccuPancy Official Use Only Department of Fire Services o. 0 L 4 BOARD OF FIRE PREVENTION REGULATIONS and Fee Checked _ APPLICATION (leave blank �1r LICAT'I®N FOR PERMIT' l'® PERF®RM ELEC�'RiC6� All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.0TIOA90 WORK (PLEASEPR8TLVWKORTYPEALLR&ORMADate: City or Town of NORTH ANDOVER —?- ----` t' By this application the undersigned gives notice of his or her intenti14 ector ores: on t perform theTo the jelectrical wf dies n'bed below. Location(Street&Number) Owner or Tenant t„ I Owner's Address 1'1 Telephone No. Is this permit in conjunction with a b ' g permit? yes No ❑ (Check Appropriate Bog) Purpose of Building_ V ' e Cl) Utility Authorization No. Existing Service Amps s / Z Q Volts Overhead ❑ Undgrd❑ No.of Meters _ N--ew—SSrvice Amps ____L_Volts Overhead❑ Undgrd E]. No.of Meters Number of Feeders andA.mpacity Location and Nature of Proposed Electrical Work: Com letion of the followin table maybe waived by the Ins ector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)FansNo.of Total No.of Luminaire Outlets Transformers KVA � No.of Hot Tubs No.of L Generators KVA cmainaires S Above Brimming Pool �' o•o Emergency d. ❑ g y ig - _- d ❑ g No.of Receptacle Batter Units • cIe Outlets No.of Oil Burgers IVE Ai APUWIS No.of Zones No.of SwitchesNo,of Gas - •� Burners No.of Detection and No.of Ranges Total Inrhatin Devices . No.of Air Coad. No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons ns Imo' Totals: ­.-- 'I• ._._......._..._........._.�No.of Self Contained No.of Dishwashers Deteetion/Alertin Devices Space/Area Heating KW Local❑ Municipal No.of Dryers Heatin A fiances Connection ❑ Other g PP KW Security Systems:* No.of Water No.of No.of Devices or Equivalent Heaters �' No.of Data Wiring; Si s Ballasts. No.Hydromassage BathtubsNo.of Devices or E uivalent OTHER: of Devices or No,of Motors Total HP Telecommunications Wiring; No. E ring: b Estimated Value of Electrical Work: Attach additional detail","desired,or as required by the Inspector of Wires. 191 Work to Start: (When required by municipal policy.) Inspections to be requested in accordance with MEC Rule 10, INSURAIyCE COVERAGE: Unless waived by the owner,no peand upon completion. the Iieensee.provides proof of liability insurance including" rmit for the performance of electrical work may issue unless undersigned certifies that such coverage is in force,and has completed operation"coverage or its substantial equivalent. The exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER I certify p 11 .(Specify:) under the pains and enaI ,of per'ury,that the 'nformadon on this application is true and complete. FIRM NAME: Licensee: LIC.NO.:. I a p Signator (f pIzp 'cable,enter --exempt"in the license number line.) LIC.NO.: Address: Bus.Tel.No.:*Per M.G. c. 147,s.57-61,security work requires Department of Public Safety"S"-Ti,.__neAlt'Tel.NO.: 20 OWNER'S INSURANCE WAIVER; I am aware that the Licensee does not have the Iiabili Laic.No; required by Iaw. By my signature below,I hereby waive thisone) ❑owner coverage normally requirement. I am the(check Owner/Agent Signature El owner's agent Telephone No. PERMjT FEE:$ 3 •� ELECTRICAL PERMIT NO. INSPECTION REPORT:ELECTRICAL INSPECTOR-DOUG SMALL 1.ROUGH INS ON: Passed— Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-no initials) Date — 2.FINAL INSPECTION: Passed—[ ] Failed—[ ] Re-inspection required($50.00) Inspectors'comments: (Inspectors'Signature-no initials) Date 3.UNDER GROUND INSPECTION: Passed—[ ] Failed—[ I Re-inspection required($50.00) Inspectors'comments: (Inspectors'Signature-no initials) Date 4.INSPECTION—SERVICE: - DATE CALLED NATIONAL GRID: NAPM Passed—[ ] Failed—r Re-inspection requireE(($50.00) Inspectors' comments: (Ins)ectors'Signature-xio initials) Date 5.INSPECTION-OTHER: F 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 TBE AREA TO SE INSPECTED IS NOT ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CIIARGED. The Commonwealth of Massachusetts Department of Industrial Accidents Office offnvestagations ..600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Dame(Business/organization/Individual): Address: 1<,LJ49- L4 City/State/Zip: Oil � 8 one#: & 0 Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. Type of project(required): ❑ I am a general con7sheet employees(full and/or part time).* have hired the sub 6. ❑New construction 2 I am a sole proprietor or partner- listed on the attac �• ❑Remodeling ship and have no employees These sub=contractors have working for me in any capacity. workers'comp.insurance. 8. ❑Demolition [No workers'comp. insurance 5. ❑ We are a corporation and its 9. ❑Building addition required.] officers have exercised their 10�6 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL] employees. [No 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4),and we have no 41 insurance,req uired. t �7�orkers' 12.❑Roof repairs comp.insurance required.] 13.❑ Other " . Plicant`tet checks box#1 m���t also ei I. �y aYY v fill out the section beloe�,shoe=,int'their wo:?:ers'comp=.sati0 policy info Watton t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: 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 Section 25A of MGL c. 152 can lead to the imposition of fine up to$1,500.00 and/or one-year imprisonment, P criminal penalties of a y prisonment,as well as civil en of up to$250.00 a da a penalties in the form of a STOP WORK ORDER and a fore y against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cce�rci unde the pains a d penal 'es perjury that the information provided above is true and correct Signature: I Date.: Phone#: i 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other Contact Person: Phone#•