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HomeMy WebLinkAboutMiscellaneous - 74 STONECLEAVE ROAD 4/30/2018l,0mmonweah4 o f a+ i"Iamachuaetb Official Use Only •�' ' c� AAPermit No. partment of Jim Jevvice9 12-L Occupancy and Fee Checked y 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: t - \ 0 - Z (AI -1 City or Town of: Q_o- A ,�cv� 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) l Lk Ctec--c- �c,�k Owner or Tenant r I v A 1 1 -7'0 t:^ Owner's Address -)'i ' SAQ,,- etr Telephone No. Is this permit in conjunction with a building permit? Yes I No El (Check Appropriate Box) Purpose of Building D w eAV ,.na) Utility Authorization No. Existing Service Ic:J Amps 0u /3LIO Volts Overhead ❑ Undgrd ❑ No. of Meters _ New Service X Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: A.- Completion Ke 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- El rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches Z No. of Gas Burners of Detection and No. Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number. I.Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers O Heating Appliances KW Security Systems:* No: of Devices or Equivalent No. of Water KWNo. Heaters of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Tel No.f Devictso r Wiring: No. of Devices or Equivalent OTHER: �g Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: �1 �i 6 e . -L, (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 ,be 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 E] BOND ❑ OTHER ❑ (Specify:) 1 certify, under thepains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: Amore Electric, Inc. LIC. NO.: ,t. Licensee: Anthony Amore Signature//;- �, —I . NO.: Al 5375 1 a hcabl nter "e ant e l cense n tuber li �'' Bus. Tel. No.: 978-372-5877 Address: � Avco pUr F�averhi , MA 6165 Alt. Tel. No.:Sot''345'`ta� *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 EE: $ Signature Telephone No. PERMIT F 41 ,r.,i ale E FOLLOWINGA- NS . URN E.YM-A.,N*...,.fL E CT 1 :7 F- :A Date ....... �.�.�. .. TOWN OF NORTH ANDOVER PERMIT FOR WIRING � �� T' Thiscertifies that....................�% .....D....................................................................................... has permissionto perform .............Q To© ............... ........................................I.... wiring in the building of........................�.................................. ................................. at ... 7./�-{........... ......................... ..... , North Andover, Mass. 0 it ELECTRICAL INSPECT lCheck # I 1 12 0 8 2 ��(� -iso" �I�iC MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �I CITY MA DATE- - / � PERMIT # JOBSITE ADDRESS - h/ e C OWNER'S NA E P OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION: © REPLACEMENTS PLANS SUBMITTED: YES 0 NO© FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 c3 BATHTUB CROSS CONNECTION DEVICE { ( [ i_ I E�, I DEDICATED SPECIAL WASTE SYSTEM _ _� I — I DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM I [ I DEDICATED WATER RECYCLE SYSTEM _ _ DISHWASHER DRINKING FOUNTAIN_ FOOD DISPOSER I_ 1 -._--__J ( -___..J __..__( ..___� __.._...__1 .___.!=E_._.,J .�-_..� FLOOR/ AREA DRAIN I �� � INTERCEPTOR (INTERIOR) —__� ( f w._� KITCHEN SINK LAVATORY T.I __—) J _I —J ___ —_---i -- ROOF DRAIN— I___J __ .__ 1 __.1 SHOWER STALL s_I _ _1 f I -_.._-_1 SERVICE /MOP SINK TC';i_ET URINAL WATER HEATER ALL TYPES WATER PIPING I f j _ OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO] IF YOU CHECKED YES, PLEASE INDICATE T E TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY© BOND Q OWNER'S INSURANCE WAIVER: m 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER Ei AGENT ISI hereby certify that all of the details and information I have submitted or entered regarding this applicatio a tru a accurat o the b st o knowledg( and that all plumbing work and installations pe ormed under the permit issued for this application will b in co i wit a n t pr ' on of the Massachusetts State PI ing Code and Cha er <2 f the General Laws. PLUM R'S NAME �,(I LICENSE # 0 GNATURE MP I JP [31A CORPORATION �f # ^ 1 PARTNERSHIP D# #= LLC a COMPANY NAME v I (q 1L , Al b vo- �ADDRESS CITY STATE ZIP t 1 TEL 1.5- - p FAX L CELL EMAIL cT M ❑ W CL Iii w LL r� 10343 A," Date .o* ............... :)WN OF NORTH ANDOVER PERMIT FOR PLUMBING ��................. . ... ./ .................. ...... has permission toperform ..11�0/'- 4"IdEd .................................................................................... 6� plumbing in the buildings of. ........................................................ led at ... ...... North Andover, Mass. Fee..Y.T—".... Lic. No. 19P6.9117.. . ........................................................... /0,) 7n PLUMBING. INSPECTOR Check # *4 -/V 01,U 11F114 - The Commonwealth of Massachusetts - Department of IndustrialAccidints Office ofInvestigations 600 Washington Street Boston, MA 02111 Uf www.massgov/dia Workers' Compensation Insurance .Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): City/State/Zip: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they Aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees: Below is the policy and job site information. Insurance Company Name:. /let V Policy # or Self -ins. Lie. #: Expiration Date: k —.> / " Job Site Address: Z Y 1 102 CJ49it ,..-P 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 requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverageyexifi cation. I do hereby certW under --(„d-5—�sv that the information provided above is true Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # —s — 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 bean 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 maybe 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 permittlicense 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachl�.setts Department of Jnidustdal Accidents Office of Investigations 6.00 Wasbington Street Boston, MA. 0.21.1.1. Tel, # 61.7-727,4900 ext 406 or 1.-877, MMSSAFB Revised 5-26-05 Fax # 617-727-7749 ww.mass,gavfdia A I C'ommonweaR o f MadsacLetb . 0pa*P"nt o/ Jim Serviced BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. � l b Occupancy and Fee Checked (Rev. 1/07j 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: /2- / 7—O,3 City or Town of: A/oRl-W 11)y/xa41c/q 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) 7Y Owner or Tenant C'L Yf) tF- Telephone No. ' Owner's Address Is this permit in conjunction with a building permit? Yes R] 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: GUrRi` i9,0.Qiiioy5u-"ROO," � Com lesion of the following table may be waived b the In ector of Wires No. of Recessed Luminaires 8 No. of Cell.-Susp. (Paddle) Fans o. o Trans formers Total KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool ove ❑ n- ❑ rnd. grnd, o. oEmergency Lighting Battery Units No. of Receptacle Outlets 9 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches (� No, of Cas Burners o. o etection an Initiating Devices No. of Ranges No. of Air Cond, Tons No. of Alerting Devices No, of Waste Disposers eat ump Totals: ......um....er.. ons No. of Self -Contained Detection/Alerting Devices No, of Dishwashers Space/Area Heating KW Local 11MunicipalElOther Connection No, of Dryers Heating Appliances KW Securitysystems:* No. of Devices or Equivalent No. o aterKN, Heaters o. o o. o Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP a ecommunicationstrtng: No. of Devices or E uivalent OTHER: 0o Attach additional detail if desired or as required b)- the Inspector of Wires. Estimated Value of Electrical Work: �Dt! (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,'lhat the information on this licatto is true and complete. FIRM NAME: DA-rrD FLEcIrgiCAL Cat`,MAe•r(4& LLC LIC. NO.: Ig963A Licensee: 'D At/t D 0A64Ak Sigriature r— LIC. NO.: (If applicable. enter "exempt" in the license number line.)) Bus. Tel. NoA7B - b8 2 - (*242 Address: 87 6ELMONT ST ISI XfW Aj�fDOVER OItNS Alt. Tel.No.:918 37S 57 3q '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: $ Cp G�-�� C1 /L �� �c� �� i � ��� ��� � - � � �� �� r PA .V I Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........... .. 77 ...-........ ............................. has permission to perform .............. 5I./.)v ... *RnR ................................ wiring in the building of .............. ...................................................... at ... ...................... v... North Andover, Mass. '74�� Lic. No.I.Y.14 -3/0 ....�'��� Fee.�Z�. ............... Check M Me Commonwealth of Massachusetts official Use only ! Permit No. n/ Department of Fire Services 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 CMR .12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: / a — ! 7 � % City or Town of: /VON- 117,14V -&r To the Inspector of Wiles: 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 �iy%�' ` �-%� Telephone No.-ff evi1g Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building �'�Ngl ,e— t�'lc{ D&/yfLlir i Utility Authorization No. Existing Service Amps / Volts Ovemead ❑ New Service Amps Number of Feeders and Ampacity Volts Overhead ❑ Location and Nature of Proposed Electrical Work: Undgrd ❑ Undgrd ❑ e, No. of Meters No. of Meters it le, e) t-1, F-1 Completion of the following table may be waived by the Inspector of lVires. ((�� .Attach additional detad g desired, or as required ay the mmpeua u/ rr r3. Estimated Value of Electrical Work: (Do • 00 (When required by municipal policy.) a Work to Start: /P--/ 7" B Inspections to be requested in accordance with MEC Rule 10, and upon completion. �1 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: (S' " dCt/t CST)''/e'v LIC. NO.: j 4 /3 1 Licensee: 5-/&z4/ A/Zf� Signature LIC. NO.Xd63lP (If applicable, enter "e.rempl" in th license number line.) Bus. Tel. No.:� ��35= 877 Address: l7 A f- S �.✓ elrly / - �1�01 Alt. Tel. No's / g� - ''Security System Contractor License required for this work; if applicable, enter the license number here:.P�/ OWNER'S i NSU RANCE WAIVER: I am aware that the Licensee does not hai-e the liability insurance coverage. normally required by law. By my signature below, I hereby waive this requirement. 1 am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. of Total No. of Recessed Luminaires No. of Ceil.-Sus P• (Paddle) Fans . Transrsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool rnd. Elrnd. o. o Emergency Lighting of Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. Detection and No. of Switches No. of Gas Burners nitiatin Devices In No. of Ranges No. of Air Cond. Tonal No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Dis osers P Totals: Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal ❑ Other Connection No. of Dryers } 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 Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or E uivalent OTHER: ((�� .Attach additional detad g desired, or as required ay the mmpeua u/ rr r3. Estimated Value of Electrical Work: (Do • 00 (When required by municipal policy.) a Work to Start: /P--/ 7" B Inspections to be requested in accordance with MEC Rule 10, and upon completion. �1 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: (S' " dCt/t CST)''/e'v LIC. NO.: j 4 /3 1 Licensee: 5-/&z4/ A/Zf� Signature LIC. NO.Xd63lP (If applicable, enter "e.rempl" in th license number line.) Bus. Tel. No.:� ��35= 877 Address: l7 A f- S �.✓ elrly / - �1�01 Alt. Tel. No's / g� - ''Security System Contractor License required for this work; if applicable, enter the license number here:.P�/ OWNER'S i NSU RANCE WAIVER: I am aware that the Licensee does not hai-e the liability insurance coverage. normally required by law. By my signature below, I hereby waive this requirement. 1 am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. m Date .;�..::=-2... �21 .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... .......... y .......................................... ................................ z2 has permission to perform ................................. wiring in the building of .... . .4, . .............................................................. at.................... C,�N!nrthh Andover Mass Feel....... � ........ Lic. NqP,13r�.9,? .................. ....... ...... ELECTRICAL INSPECTOR Check # M P MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) I- ` Mass. Date -0-7 Permit # Building Location 7 /i Owner's Nam /1 Na Type of Occupancy Residential Installing Company Name Heritage Htg. &Pig. Co. Inc. Address_,___ Check one: Certificate 35 Pleasant Street CX Corporation 714 Stoneham, Ma 02180 Business Telephone 781 L Partnership Name of Licensed Plumber 8-7776 Firm/Co. Gordon Switzer -�- INSURANCE COVERAGE: I have a current liability insurance policy Or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes Ej No ❑ If you have checked Vis, please indicate the type coverage by checking the appropriate box. A liability insurance policy —M Other type of indemnity ❑ Bond ❑ OWNER'S !NSURANCE 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 detaiis and information I have submitted (or entered) in above application are true and accurate to the best of m,; knowledge and that all plumbing vrork and installations performed under the permit issued for this application will be in compliance with ail Pertinent provisions of the Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws. By i Title Sign ure of License 'Plum er --- City/Town Type of License: Master Journeyman ❑ APPROVED(OFFICE US ---E otiLY) License Number 8322 �Z" Watts 9D bCp on water line to water boiler--- C --L,�/ New Renovation V Replacement Plans Submitted: Yes ❑ No ^,' FIXTURES l Z z c� -1 cn O Z f l u x J cr } o Q z =' w O C7 W I 1 J L7 w N C c=~ N r- �� U a o z w N ` a¢ N to S r x i v ¢© O n _ ¢ c w < w c� r Q n a _ < 3 1-� RS ry w y l a i Q 3 m o o Q w — O Q > J m ¢ cn Z 0. J f i t I Q v F Q Q s = n a z yr m x x z r v' Z O p a x UJ Z z w j- J x 7 t S 1 lQ�� i 1 3 x J m v> o O~ 3= m J Q e¢ a O a r -r 4q-J)� +t O O Q 3m •N 10 rt3 rd rC3 f�� SU8-8SMT- ! J 3 V] BASEMENT 1ST FLOOR 2N0 FLOOR 3 R 0 FLOOR 4TH FLOOR 5THFLOOR 6TH FLOOR 7TH FLOOR i 8TH FLOOR r Installing Company Name Heritage Htg. &Pig. Co. Inc. Address_,___ Check one: Certificate 35 Pleasant Street CX Corporation 714 Stoneham, Ma 02180 Business Telephone 781 L Partnership Name of Licensed Plumber 8-7776 Firm/Co. Gordon Switzer -�- INSURANCE COVERAGE: I have a current liability insurance policy Or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes Ej No ❑ If you have checked Vis, please indicate the type coverage by checking the appropriate box. A liability insurance policy —M Other type of indemnity ❑ Bond ❑ OWNER'S !NSURANCE 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 detaiis and information I have submitted (or entered) in above application are true and accurate to the best of m,; knowledge and that all plumbing vrork and installations performed under the permit issued for this application will be in compliance with ail Pertinent provisions of the Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws. By i Title Sign ure of License 'Plum er --- City/Town Type of License: Master Journeyman ❑ APPROVED(OFFICE US ---E otiLY) License Number 8322 �Z" Watts 9D bCp on water line to water boiler--- C --L,�/ } z O W N D w U LL U- 0 0 ccO SU. Y O J W m N W U w YI N Date. A ......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING chis certifies that ................... has permission to perform .,� o`' ������................ plumbing in the buildings of . ;`U ?.......................... . at .......... North Andover, Mass. Fee�� uJ .. Lic. No. !43 .. ? .............. . -'PLUMBING INSPECTOR Check .", .n Z1 C� 8340 " Official Use Only CommonW64114 o/ madeaclWet ! 1JaParfmant o��ira Jarvicae Permit No. aso 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: 6 / &7 - Ci or Town of: &Iao x� h' DA e< 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) S72;, 4 �C���9t/L� Owner or Tenant L u/o mu- Telephone No. • Owner's Address 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: ,�'/7Z-Hc'4�, �96,kzocof 97&�-, Com lesion o the Ilowing table maybe waived b , the In ector of Wires No. of Recessed Luminaires 12 No. of Cell.-Susp. (Paddle) Fans o, of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Lumi6aires Swimming Pool Above ❑ n- ❑ITO-7-017Effiergency rnd. grnd. Lighting Ba"ery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches .3 No. of Cas Burners o, o etectton an Initiating Devices No. of Ranges / Total No. of Air Cond, Tons No. of Alerting Devices No. of Waste Disposers eatum Total P Number ons " ""'"' o, oSelf-Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ un cipal [3 Other Connection No. of Dryers Heating Appliances KW Security ystems:* No. of Devices or Equivalent No. o KW Heaters o. o o. o Signs Ballasts Data Wiring: No. of Devices or Ec uivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsWiring: Z No. of Devices or Equivalent O"rH ER: cir --- Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 36150 (When required by municipal policy.) Work to Start: b111710 --q inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE OVERAGE: 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 cove a 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 o perjury, that the information on this applic ion is true and complete.. 1 FIRM NAME: DAV t D E(,E' ,'%RI C i- Gp/�f1' 1CT LIC. NO.: t`79�a 3>4 Licensee: ZIAV 10 ;+ACaCo&rZ Signature LIC. NO.: (If applicable, enker "exg�mpt " in the license number line.) Bus. Tel. NO.: J�26�6 Address: ? 13CLN10NT- ST 1JOlZilf �gN�yCQ ' S5 Alt. Tel. No.:q7Y 3055"'7341 '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. 1 am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No, PERMIT FEE: S (--tq� d-t-cl -7 � Z 3,o t A� w Date.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......1 111.11. 4zt� �f11r . ................................. has permission to perform ........... k— Z. /- 7 ......................................... wiring in the building of .............. . .................................................. at .... 7fe ....... i6Wl ........ eo ....... . North Andover, Mass. ob Fee .�O ........ L i c. No. MV ......... . .......... ELECTRICAL INsP Check # �CTV MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location �� S-rbn?, 6a) Owners NambL& New 1:1 Renovation of Date Permit 77=7777 G Amount�y� Replacement 1:1 Plans Submitted Yes 0 No ❑ (Print or type) LL 0 -" Check one: Certificate Installing Company Name 'Al p Co rP Address3 �© W. � Partner. tKe4NL14MO., 019LW usmess Telephone -7 v Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate th 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 IOwner I hereby certify that all of the details and infor best of my knowledge and that all plumbing we compliance with all pertinent provisions of the By: Title City/Town APPROVED (OFFICE USE ONLY 11 1 State Agent entered) in above application are true and accurate to the ied under Permit Issued for this application will be in ng Code chapter 142 of the General Laws. Type of Plumbing License icense rqumoer Master Journeyman ❑ Date. � � e 1, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .........` has permission to perform -" L1'?,^ � �� ". ........... ✓ plumbing in the buildings of .................. . at.North Andover, Mass. Fee Lic. No.// oo .,.C........ ............... Pl �,MrBING INSPECTOR Check s w The Commonwealth of Massachusetts k� )! Department of Industrial Accidents Office of Investigations ,; 600 Ilrashington Street U Boston, MA 02111 c ' www_massgov/din A licant nformation ffi Workers' Compensation Insurance Affidavit.- Builders/Contractors/Electricians/pimber�s I Please Print Legibly Name(Businms/Orgaoizaiion/}ndividual). 0VVk / Address:1��vlh l Ct-)j- �. City/State/Zip: Phone #:. Are you an employer? Cheek.the appropriate box: 1. Faro a employer with 4. ❑ I am a general contractor and I Type f pralect (required): employees (full and/orpart-time).* have hired the sttb-contractors b. New construction 2. I am.a.so}e proprietor. or partner_ listed on the attached sheet t 7. Remodeling ship and have no employees These sub -contractors have 8. Q Demolition working for me in any capacity. workers' comp. insurance. [No workers comp. insurance 5. 9• ❑ Building addition P ❑ We are a corporation and its required.] officers have exercised their 10. [1 Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions myself. [No•workers' comp, c. 152, g 1(4), and we have no insurancereN fired.]. t .employees. [No workers' 12.[]Roof repairs comp. insurance required.] I3Other `Any applicam that checks boz' # I must also fill out the section below showing their workers' bbmpensation Policy information t Homeowners who submit this affidavit indicating they are doing all work and then him outside connaetots must submit a new affidavit indicating such, =Cantmetors that check this box must a�ehed an additions! sheat showing this name of the sub-eontmetots and their workers' ccmp, rolim • irfanna#or.. 1 am an employer that isProvidw9 workers' compensation insurance or information. MY m1' employem: Below is the policy andjoh site . Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/Statezip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration daPej, Failure to secure coverage as required. under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 an r 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 ag�fr the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA nsurance coverage verification. 1 do hereby certify olPed K7 that the information provided ahove isfwe i Date: l 7 / 0 Phone #: F ffciat use only. Do not write in this area, to be completed by city or town ofrxaL City or Town: _ Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 6.Otber 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone #: Information a nd Instructions Massachusetts General Laws chapter 152 requires all emp 3 oyers 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 includirig 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 I52, §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), armd phone numbers) along with their certificates) of insusance. 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 shouid 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 numberlisted below. Self-insured w7manim chnniri _n+nr the;r self=insurance license number on the appropriate line, q City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department his 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 permittlicense number which wiII be used as a reference number. in addition, an appiicant 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 -tire affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affmdavrt 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 bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of industrW Accidents Office of Investigations 600 Washington Stmt Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-977-MASSAFE Fax # 617-727-7744 Revised 5-26-05 www.mass,gov/dia