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Home My WebLink AboutMiscellaneous - 73 PLEASANT STREET 4/30/20180 bq I Date ........ k ......... ..... . .... .... .. .............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ............................................... 4....'1 ........................................................... ..... has permission to perform ....... ...i ......... ................................ wiring in the building of .... A-1-1.17 ................................................... at ......... ......... 52 ................................. . No Andover, Mass. Fee Li c. No . ................. ....... ELECTRICN S PEC TOR Check# 4) 41d 2, 16' 12 (fommonwea& o f )&Jachudetti 2epartment o f Jim Seruicea Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE74Yl FORAPTION) Date: City or Town of: / 41n ��/ � To the Inspector of Wires: By this application the undersigned g'ves otice of his orgher inteption to perform the electrical work described below. Location (Street & Number) Owner or Tenant yt Owner's Address 73 2 , cto Is this permit in conjunction with a building permit? Yes ❑ Purpose of Building Existing Service 00 Amps New Service sT_ Amps Number of Feeders and Ampacit Location and Nature of Proposed /7/�t/4 - r O�l% � ,t 4- Telephone No. 9�" 6-8-5p No ® (Check Appropriate Box) Utility Authorization No. 6.0) �r� 7 t'�Volts Overhead ® Undgrd ❑ No. of Meters a i / O Volts Overhead 0 Undgrd ❑ No. of Meters 2 y 7T, -o _'42eyPr5 6 460A Electrical Work: ��2/w :(r/tce 42 9220a?�� Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. rnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pum Number * Tons * * * KW I ........................ No. of Self -Contained Totals I Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW ecurity Systems: No. of 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 Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: ?- 29-15- 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: /� _ LIC. NO.: Licensee: AOIZI- ¢ &/k -d-12 Signature LIC. NO.: f� (If applicable, enter "e�x%e�p," in the license u ber line-)/ Bus. Tel. No.: 665 3563 Address: CD �1D�G�,S�� ///�% 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 PERMIT FEE. $ Signature Telephone No. V b 1 r The Commonwealth of Massachusetts z w Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia «porkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: City/State/Zip: Are you an employer? Check the appropriate box: Please Print Phone #: 40__�5 VJam- 91yr 1.❑ I am a employer with employees (full and/or part-time).* 2 1 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.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.❑ 1 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. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition I L[K Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13.❑Roof repairs 14. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit 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. If the 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: Policy # or Self -ins. Lie. #: 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 fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify of perjury that the information provided above is true and correct. 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. Plumbing Inspector 6. Other Contact Person: 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 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-contractor(s) 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. 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 "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 www.mass.gov/dia IN ,i r Date ....-..-xz.�... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that &45.s. aN . C'4. . f.... has permission to perform...�/�S �v�-�t•� .......................... ........................f ................. wiring in the building of ..........�.. C...... �. 5..! ........................ at ...... 5.-~' .................. orth Andover, Mass. Fee....... d........... Lic. No.././ 8 - ............................ ................. ELECTRICAL INSPECTOR U Check #V 7 #2r i C'ommonwsa& o` l /%amac4usaffi U MIR= MUM llepar&wnt of ire JemiceA BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. L1 1 OR Occupancy and Fee Checked [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: g %. City or Town of: ✓ o . /�,ov��L To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 7 3 f,7LC,4yA v -r Si Owner or Tenant �,�pj,G s. k t. Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (- (Check Appropriate Box) Purpose of Building 1A) L, )X 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:L✓//Lr oJ/�S it,eiv�C� �,yG.'}Cfir y,, r Z/N .$ 7Y� Lt C,� O1� i-YGt�TUtL Attach additional detail if sired, or as required by the Inspector of Wires. Estimated Value of Electrical 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:) General Liability 12/31/09 1 certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRMNAME: Boissonneault Electric Corp. LIC.NO.: 11823A Licensee: _11N.'Lrr71, / 4,;r Signature/� % -s-- r IC. NO.: 2 yG90 ffapplicable, enter "exempt" in the license number line.) Bus. Tel. No.:—Q-7 8 4 5 4 — 0 3 8 3 Address: 36 Chuck Drive - Dracut, MA 01826 Alt. Tel. No.: — 977 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ,uwe muy ae waived by the ins ector o Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of ota Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ n- E:] No. or Emergency Lighting rnd. ernd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection an Initiating Devices No. of Ranges No. of Air Coad. Total Tons No. of Alerting Devices No. of Waste Disposers eat Pump Totals: .....um... er ons " """" ""' ........................Detection/Alerting o. o e - ontained Devices No. of Dishwashers Space/Area Heating KW Local ❑ Conneectiunrctial on El other No. of Dryers Heating Appliances KW ecurity ystems: No. 0 of ater Heaters KW o. o o. o Signs Ballasts of Devices or E uivalent Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP a ecommunicationsir!n g: No. of Devices or E uivalent OTHER: Attach additional detail if sired, or as required by the Inspector of Wires. Estimated Value of Electrical 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:) General Liability 12/31/09 1 certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRMNAME: Boissonneault Electric Corp. LIC.NO.: 11823A Licensee: _11N.'Lrr71, / 4,;r Signature/� % -s-- r IC. NO.: 2 yG90 ffapplicable, enter "exempt" in the license number line.) Bus. Tel. No.:—Q-7 8 4 5 4 — 0 3 8 3 Address: 36 Chuck Drive - Dracut, MA 01826 Alt. Tel. No.: — 977 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ 0% Date .....t,? ........... NpRTry pF „ao 4•p TOWN OF NORTH ANDOVER . T • PERMIT FOR GAS INSTALLATION This certifies that ..... . ... . has permission for gas nstallation . ..... ................. . in the buildin s.of—, . .......... c.....? ... .- ..... ......... . at !� g+.�..� , North Andover, Mass. Fet. . ..... Lic. No '� ............. . GAS Check Check # '�-3e�'v'`- 6493 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) G N ORV xmoyc . Mass. Date g % Permit # Building Location PLEASANT S7•. IST Owner's Name [)AN IEL Lf T2DLt),�K i Nim A A NflQUER HA Type of Occupancy /2�S 1 n AJ71 A L New ❑ Renovation ❑ Replacement Plans Submitted: Yes[] No ❑ kinstailing Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET Corporation 1862 LAWRENCE, MA 018 41 - 2312- ❑ Partnership Business Telephone q 7 lB- 6 8,7 -110 5 Exr *306 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have aY uSrrenntt liability Ins r❑,ce policy or its substantial equivalent which meets the requirements of MGL Ch. 142. If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy X . Other type of indemnity O 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 taws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's agent , owner[] Agent ❑ hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accur to to the best of my knowledge and that all plumbing work and installations performed under the permit lss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. (/ i By T of License: Plumber Signature of Licensed Plumber or Gas Title Gasfitter Master License Number 374 5 City/Town Journeyman APPPOVEffO IC SE O i ' z - o_ n h w 0. N Z N N W cc n O a 0. a. NI W m v� w W x N z 0 Z • 'ter J d z LL. O z d J n z• t - a. N Q J n z O o N a f- w • a U. z z oQ IL a cc J O 0 fi U. Z C] d0 O J �. W w d 0. m U �. J � CL a W � w a LL z NI W m v� w W x N z 0 Z • 'ter J d z LL. O z d J Date ...�..-� ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that.,..:. ...... ?.............................................. 0-4 has permission to perform......,;.:. d - •tet -.....,. `....................................... w: wiring in the building of"� `.!s, ......r�,�..z1. ................................ a at ..................;:,,`.:'............. , North Andover, Mass. Fee. ...... Lic. No.I;�S� ........./ l .r ELECTRICAL INSPECTOR Check # 1.12 4720 THE COMMONWEALTH OF AWSACHUSEM DEPARTNIEW0FPUBIICS4FE7Y BOARD OF FME PREM77YONREGUTATIONS 527 CNIR 12.-00 APPLICATIONFOR PERMIT TO PERFORM ALL WORK TO BE PERFORMED IN ACCORDANCE WTPH THE MASSACHUSSTS ELECTF (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Office Use only Permit No. 1-1-12-0. &Fees Checked zxJ WCAL WORK 527 CMR 12:00 /ry Date 1,2w— O (� To the Inspector of Wires Location (Street & Number) 7 7 PL t 19f ,4 ivy 5'7 -- Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes El No F-1 (Check Appropriate Box) Purpose of Building 2 S1 Uf /ll 71 A Li Utility Authorization No. Existing Service Amps 'Volts Overhead Underground ED No. of Meters New Service Amps / Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work q IF /-i F '14 7 No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA . No. of Lighting Fixtures Swimming Pool Above Below F1 Generators KVA ground El ground No. of Receptacle Outlets No. of Oil Burners 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. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER- 1- VoeGGA2 ALA 2/1 h>sutalxeGDW age: Rinanttodie recpvternaltsofMas�G malLaws Ihaveaaurartliabilityhm> ncePbficymckidingCmplete Opphons Cowrdgeoritssulutntalequivabl YES M NO IhavesubrrtiWdvandptoofofsametodrOlhoe. YES IfyouhawdrekPdYES,ple2s--in&a1ethetype0f00W[a�Pby ddngNSSNCboE INILRABOND M GIHER r7 ( SM*) FxpnatronDate Esti Valueofl7eclricalWodc $ Wotktostart — % Z- kWecttonDa-Regtrested Rough Final sign edunderTi-P' � n Aesofpe 4ury: FIRMNAME S(/ L L / v /% /V AIV 7• f �G ii �� LicemNo. Licerrs� �D /. /0 % f(l///!// ue ��a /Lo�i1 ��.GG�y t No V % Z�> BusirtessTeL No. 9 79- 6 J.2- G Y 7V EA OWNER' S INSURANCE WAIVER; I am aware that the Lict'am does Dot ba, and that my signahue on this permit application waives this requrrummt. (Please check one) Owner Agent rgnature ot Uwner or Agent Alt Tel No. its arbontial equivalent as requned by Masswhusetts Gerrfal Laws 011 Telephone No. PERMIT FEE $ X� Name The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: Location: City Phone # 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. Company name: Address City: Phone # Insurance. Co. Policy # Company name: , Address City: Phone #: � Insurance Co. Policy # 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 $1,500.()0 and/or one years' imprisonment_as_vitell_as_civil.Renaltiesinlhelnrm-f-a_ST_OPWORK..ORDFR.and_a.fne_cf_($111.0M)-a -day zgains2.rne, 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 under the pains and penalties of perjury that the information provided above is true and coned Signature. Print name Official use only do not write in this area to be completed by city or town officiar City or Town Permit/Licensing D Building Dept ❑Check if immedrate response is required L Censin9 Board, p Selectman's Office Contact person: Phone # El Health Department Ei Other