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HomeMy WebLinkAboutMiscellaneous - 740 FOREST STREET 4/30/2018 (2)' a 0 n Ln W I bm m This certifies that ...... . . has permission to perform ..... / .�6n wiring in the building of S ..t=- ...... . . . . . . . .. . . at .. ?- � ../� ;, f&5 s , , , , ,5,.,,-- , , , , , , , , . , North Andover, Mass. Fee .� Lic. No. �?� 77/,,�f..... p.� ELECTRICAL IN PECTO Check # 11091 -\ Cemmonweat o` /Naddacl ueaMd Official Use Only A cc�� partmed of .� 6w SIr .1.4 Permit No. BOARD OF FIRE PREVENTION REGULATIONS 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 (MGC), 527 CMR 12.00 �,. (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: !Mbember IU t aoia. City or Town of: O,r,&)- , A nc ue r To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. \V N Location (Street & Number) %YO Fccp4- ice OwnerorTenant S-Lunc+ -1-TAnmTSnn Telephone No. &7g)bA�1-75-W (� Owner's Address &.Xae cis O,606e y Is this permit In conjunction with a building permit? Yes No ❑ (Check Appropriate Box). e Purposcof BuildingUtility Authorization No. Existing Service _4 00 Amps 19-0 / oM Volts Overhead ❑ Undgrd [Z No. of Meters INN SCITiee Amps / Volts Overhead ❑ Undgrd [:1 No. of Meters Number of Feeders and Antpacity Location and Nature of Proposed Electrical Work: (k6ey rvbuh4--rA PkesEg.taz< CPy�st� t`14A,-A "I'l ) �o1O. C S i.C. Grkc(,-a-iet. Completion of theollowin table may be waived by the has ector of Wires. No, of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans o. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above n- Swimming Pool rnd. Q rad. o. o Emergency Lighting Batter Units No, of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. o etec on an Initiating Devices No. of Ranges y Total No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers p cat ttmp Totals: , um ,er "ons .. ""'"""""""" o. o e - onto ne Detection/Alerting Devices No. of Dishwashers Space/Arca Healing KW Local tj Municipal ❑ Other Connection No. of Dryers HeRtin Appliances g pp KW -security Systems:* No. of Devices or Equivalent No. of Water KW oN f o. o Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications ring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, a• as required by the Inspector of lVires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Statt:A.S.A,-e. inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no hermit 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. CIRiCKONE: INSURANCE N 130NI) ❑ O`I'I(L:R ❑ (Speci(y:) I certify, under the ains and penalties• of perjury, that the information on this application is true and complete. FIRM NAME: _ Odor, LIC. NO.: a 71 A Licensee: Signature ,_ _ LI(:. NO.:,g i e7 TO, ("!/'applicable, enter "exempt" in the license number line.) Bus. '('el. No.t—�T--Nisf05 Address: Q1Ij84..tjrU0 fir. %, ;td; .a✓tl. &I �p %��Cti _ �_. Alt. Tel. No.:.s'�� �ZQS. *Per M.G.L. c. I47, s. 57-61, security Ark requires Department o ublic Safety "S" License: Lie. No. _r 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) E] owner ❑ owner's agent. Owner/Agent Signature � �- �_ "Telephone No._�___ _.___.�._ ..PERAIIT FEE: $ �� f- j'' I The Commonwealth of Mtrssachuseiis Print Form Department of Industrial Accidents ' Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name (Business/Organization/individual): SolarCity Corporation Address:3055 Clearview Way San Mateo, CA 94402 Phone #:650 963-5100 Are you an employer? Check the appropriate box: , 1. 1 am a employer with 1500 . 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 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. employees and have workers' [No workers' comp. insurance comp. insurance.$ 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling K. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.E OtherSolar Installation *Any applicant that checks box #] must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit Ibis 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: Zurich American Insurance Company Policy # or Self -ins. Lic. #:WC96734670 Expiration Date: 9/01/2013 Job Site Address: -7 40 Focec& StmA City/State/Zip: 1 },8YAouer, MA 0ljg5 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 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 coverage verification. I do hereby certlfy ander the parrs penalties of perjury that the information provided above is true and correct Phone #:774-226-0769 Oficial use only. Do not write in this area, to be completed by city or town official. 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O!a U aC ri O am+ LL 7 N N v1 -+ O `-• of m v+' E c O. y 11 • • • • • • Q m V O W O V J_ Q Lq N U N N C) J O O C7 — C) O J J Z O 00,^ 57– Lo 0 Q O M ��=O W y^ =� (O W D m � aw mp W • ZZ� Z W �O1-Tf �J W QLLJa N i �OOCOV H0. 0 U W ? ?F-WU �N WZa O W N W? a N aye~�6 LLJ oe oQZ�as0 ~ Z Z a CNK U' W� C U U m 2'L O V N a 9144 Date. �.. •�,;:�tiooL TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ..!t!'!C./ 0 14S , .. . . . . .. . ..... . has permission to perform ...119ee?o. . .. ............ . plumbing in the buildi gs of ..S E'.lc�Q/'' .. pml4a:f .. , at .. �(��' . reS... -ST ............ . North Andover, Mass. f 5 U /S'"z -r. /t/ % Fee .�.. ... Lic. No. .. ../.7/.C.. � ��.�v�-�..... . �j PLUMBING INSPECTOR Check # 7�" -rU T f _3 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING wLy/ i own: �!U µl/I �d Vi//___i_ MA. Date: ( Permit# Building Location: ' m�- Owners Name: IType of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential-' New: [] Alteration: ❑ Renovation: FIXTURES Plans Submitted: Yes n No InstaPlir, t e, ! r' `amt �C l �ia LG i Itn i? I One Can �a ly �� aJJcr� t �:. 'C O Address�� � �-� Cit r )'W El Corporation �--P--�,.— y/Town:m�'1.Y(�(i� State•�('i- Business Tel: •IJ - owl -33 C) 3 ❑Partnership Fax: Name of Licensed Plumber: I ` ` ��s ��� � la's I ❑Firm/Company DEDICATED rU H O ? Z a Y � F H Z iL d W Cn Z Z Y y Q En u U �� . W Q CQ'J o m Q O a W z o z FFM Q � 2 h O Q Z 2 0 0 ❑ a W z J C7 Z u a X LL cC Q `n = O O H O O O Ln a z z y F w C> O 'SUB BSMT. BASEMEN 1sT FLOOR 2 N FLOOR I 3RD FLOOR NT" FLOOR iFLOOR FLOOR 'T" FLOOR '`'FLOOR Plans Submitted: Yes n No InstaPlir, t e, ! r' `amt �C l �ia LG i Itn i? I One Can �a ly �� aJJcr� t �:. 'C O Address�� � �-� Cit r )'W El Corporation �--P--�,.— y/Town:m�'1.Y(�(i� State•�('i- Business Tel: •IJ - owl -33 C) 3 ❑Partnership Fax: Name of Licensed Plumber: I ` ` ��s ��� � la's I ❑Firm/Company DEDICATED IINSURANCE COVERAGE: 1 have a current Iia_ bility Insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 Yes 2"N o ❑ 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 Sic1nature of Owner or Ownees A ent Owner ❑ Agent ❑ 1 herebcetall ofthe details and information I have submitowledgeand thatalf plumL�ing Lrork and Instalfatio��s performed undertheperm' issuedgolrtfiis ap�plic�atioRretrueandaccun will he in ccompliance with ail rtinent provision of the Massachusetts Slate Plumbing Code and Chapter 742 a Genera Laws. a.e to the best of my 3y Type of License: -itle 6astermber Signature of tcensed Plumber �ity/Town ! PPROVED (OFFICE USE ONLY) ❑Journeyman License Number: O a � F H j I Q CQ'J U' C7 �I IINSURANCE COVERAGE: 1 have a current Iia_ bility Insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 Yes 2"N o ❑ 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 Sic1nature of Owner or Ownees A ent Owner ❑ Agent ❑ 1 herebcetall ofthe details and information I have submitowledgeand thatalf plumL�ing Lrork and Instalfatio��s performed undertheperm' issuedgolrtfiis ap�plic�atioRretrueandaccun will he in ccompliance with ail rtinent provision of the Massachusetts Slate Plumbing Code and Chapter 742 a Genera Laws. a.e to the best of my 3y Type of License: -itle 6astermber Signature of tcensed Plumber �ity/Town ! PPROVED (OFFICE USE ONLY) ❑Journeyman License Number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 * www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers -lame (Business/Organization/Individual): J Address: (� ,jj< Cpa�j City/State/Zip: I" Phone #: Are an employer? Check the appropriate box: 1. I am a employer with f 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. I 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.] i 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 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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 it or Self -ins. Lic. #: Expiration Date: Job Site Address: 1A n cap�',o�-� 54- h16r-_UL &SQ1641' City/State/Zip: V1A1ipj(-� Y I 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 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 Investigationsp ie IA_or insurance coverage verification. I do herepy certi �r the pa i s and penalties ofperjury that the information provided above is true and correct. /0/1.2/1 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 #: COMMONWEALTH OF MASSWCHUSETTS', IN PLUMBERS AND GASFITTERS S CT LUMBER LICEqR�YIOPA :-NICHOLAS P SAVVAS ;METHUEN 01844-82,16 a, 1011212011 11:51 Sullivan Insurance & Financial (FAX)9783732281 P.0011001 �Q CERTIFICATE OF LIABILITY INSURANCE °ATE(MMID°"YYY' `�" 10/12/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed., If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Diane Fraioli NAME: Sullivan Insurance & Financial, Inc. PHONEFAX (978) 372-2790 (AIC. No: (978)373-2281 487 Grovelaad Street E-MAIL dfraioli@sullivanIF.com F AnnRSS• Haverhill MA 01830 INSURERA:COnmlerce Insurance INSURED INSURER B : Savvas Nicholas, DBA: Nicholas Savvas Plumbing INSURERC: P.O. BOX 5027 INSURFRD" Andover MA 01810 1 I INSURER F: I I rnVFRAnFS CFRTIFICATF NIIMRFR•CL11101201396 RFVISIf)N NIIMRFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MMIDDIYYYV POLICY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMSMADE ❑$ OCCUR BCRVKV 0/14/2011 0/14/2012 DAMAGE TED PREM SESOE. occurrence) $ 100,000 MED EXP (Any one person)$ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS- COMP/OP AGG $ 2,000,000 $ S POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT E accid t 1,000,000 BODILY INJURY (Per person) $ A ANY AUTO ALL OWNEDSCHEDULED AUTOS g AUTOS NS677 1/14/201111/14/2012 BODILY INJURY (Per accident) $ X g NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ Per accident CICAD $ UMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB DED I I RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y 1 N E.L. EACH ACCIDENT $ ANY PROPRIEiOR/PARTNERIEXECUTIVEF-1 OFFICER/MEMBER EXCLUDED? NIA E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) Plumbing and Heating Contracting %.cm nri%.Akic nvL ueK GANGt LLAIIUN ( 978) 68 8- 9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of N. Andover ACCORDANCE WITH THE POLICY PROVISIONS. ATTN: Plumbing Inspector 120 Main Street AUTHORIZED REPRESENTATIVE N. Andover, MA 01845 .............................. Holland/KJG ...::. At:UKU ZO (ZUTU/UO) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 (201005).01 The ACORD name and logo are registered marks of ACORD ❑ 2012 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.G.L. c. 143, § 3L. Permits shall -be limited as to the time ofongoing construction activity, and maybe.deemed-bythe,Inspector_of_Wires abandoned_and_invalid.if_he—. _ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extendingthrough August 15, 2012. r8 — Permit/Date Closed: -- ! �j * Note: Reapply for new permi ule Permit Extension Act — Permit/Date Closed: ,'i 0342 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................ . L has permission to perU TGA tHebuilding of .....�.�'� T r -r'2 ................................................ z at .......�!..�i�1�� ....... ��.,?................ r..T............... b�prth Andover, Mass. Fee .....¢.� .Lic. No......Sze....... i CTRICAL INS WC R Check # Z2 -3 4- i.. atluiwinvaa&,. a/ m7wdachu3offd 20parfnwnf a15ira sorTJiew BOARD OF FIRE PREVENTION REGULATIONS Official Use Only - PemiitNo. q Occupancy and Fee Checked [Rev_1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORD All work to be performed in accordance with Hie Massachusetts Electrical Code (11MC), S37 CMR 12.00 (PLEASE PRNTDVEVK OR TPPE.�= WFOR1l ATIO Date: 16 • J ' f l City or Town of: NOf4 AN 00\16r- To the Inspector of Mies; By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street& Number,),^�1f1, EQIeCS j S Owner or Tenant STU 4 A 7 4o r P S O *l Telephone No.97d' 6Y?— 7,�Lff Owner's Address 71-/Q1� G 12C S r Is this permit in conjunction with a building permit? Yes 2r No ❑ (Check Appropriate Box) Purpose of Building (Z(,—S 10C NC (' utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps ! Volts Overhend ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Id, Tiq LL- I-6 C/ "i S I^I /; I TCM CN _ t i910D e UT(C T C I I-Cri b TO /a FL00a t3F�T AQ M J- CNI�NGC F1XR -rC-- rnnenlcTen). nrll.e r 11.e.nT.ee mAl. ".— u 1.n.o..:.....JT... d... L_-_-_._ _rive___ No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Tans No. of Total Transformers ICVA No. of Luminaire Outlets No. of Hot Tubs Generators ICVA No. of Luminaires Z Swimming Poo! Above E]In- E] rnd. grad. No. o mergency Lighting Battery Units No, of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection an Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Wnste Disposers HentPump Totals: NumberiTons 11C.W No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Beating ICW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances INV Security Systems: No. of Devices or Equivalent No. of (liar ICI•Y Heaters No. of No. of Si ns Ballasts Data Wiring: No. of Devices or E uivnlent No. Hydromassage Bathtubs No. or Motors Total HP Telecommunications Wiring: No. of Devices or Eclulvalent OTHER: . t Estimated Value of Electrical Work. Alla Clt additional detail ►Jdesired, or as required by Ilia Inspector ofD Tres. (When required by municipal policy.) Work to Start; Inspections to be requested in accordance with MEC Rule 10, and upon completion - RAGE,: -Unless -,,vaivcd-by-tba=owncr; ompletion_RAGE,:-Unless-waived-by-the=owner; nn=permit for iiia perfarmatice bfelect icon workmey=issue unless the Iicensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such c verage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER F-1 (Specify:) I certify, under ilia pants and p alifes ofperjury, that the it formation oe this applicatfou is true attd complete L FIRM NAME: - \C, P 6"NCT) 04 9 9 1 LIC. NO.: ?9y Z G Licensee: CQ\ C f M AgD Signature LIC. NO.; 39S -Z.6 (lfapplicable, enter "exempt e' in the license nwnber line. Bus. Tel. two:, Address: qSC_ mom lrtOT- N 0) It ORACU � 01 92,C, E Alt Tel. No..r *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 ant Owner/Agent Signature Telephone No. PERMIT FEE: S 1 0261 Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........... L ... ............ .................................... has permission to perform ..... ....... wiring in the building of .......... ........................................... at ......... 7Y ....................... ... .. , North Andover, Mass. mb Fee.. Lic. No. �0 ....... �Z INSPE AELLEc-mc I SPE OR Check # Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. t ` Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leave blank vs, , -- 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: !� 30 % City or Town of: NORTH 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 & Number) -741Q Fne( S )— Owner or Tenant • T(U,19 _rPO&) P SQAI Telephone No. � 337 $ 44LI0 Owner's Address _7qQ FQ PECS r Is this permit in conjunction with a building permit? Yes ❑ No.4�T (Check Appropriate Box) Purpose of Building (� Es) f N C (:� 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: CNAN6c eyrS- /Y )Q 1/aj 2OQ A Ptly - Com letion of the ollowing table mav be waived bv the In ector 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. E] o --.o Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number ....................................................... Tons KW No. of Self-Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water Kms, Heaters No. of No. of Signs Ballasts Data Wiring: 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: 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 forc 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: c PC tu.11",1 LIC. NO.: 37S7 6 C- Licensee: & t G PC` u,19N'D Signature C,4, LIC. NO. Jq :�Z 6 r (If applicable, enter "exempt" in the license number line.) Bus. Tel. No..• q7T (al fg2t4 Address: 44576 M/9^1^ cn-1 9-1) �/9 Mie • �g�Alt. Tel. No.:q7f !K'? 0?� *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 Owner/Agent PERMIT FEE. $ —� Signature Telephone No. Ae The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): LPaAAJ Address: /-/S—(o M J�lYl M 0-TH Pt. 0 City/State/Zip: QkftC r /YIA, Q)� Z ( Phone #: 9-)g 9s? CC6G ( /tee 610q 892q Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2 -0 -1 --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 11.0 Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other *Any applicant that checks box 41 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 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 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 coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 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 #: o 1pVVN Date pERM�rNoRTh / ThsFoR ANO has rmil les that wfnR i SS�Oh to fo �`r nn at ..h the buil ,%� •. , �n Of G Cheek No IV `—� o`er ec .. conunonurea[t� o� i�lad3achu6ettd dApartment of ire S is u BOARD OF FIRE PREVENTION REGULATIONS 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 TYPE ALL INFORMATION) Date: Z — 2y �/- City or Town of: (\/. )9 n d © 1/ p 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) ? q L) F6 t e S i- S+c e eA Owner or Tenant S -Vv 4r } Owner's Address 7L10 (—'o Telephone No. 978 - 6 82- 7 sir y Is this permit in conjunction with a building permit? Yes CK No ❑ (Check Appropriate. Box) Purpose of Building SOLAR FV SYS TEM 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: Ro ®�- ►'vlo i) n +-rd D k)o 'fo V o /f-Ck l C (PV) Svc _reskf 5, 52 Kw -!JC @ 5,L C G'r,d --r,fd Completion ofthe followine table may be waived by the b,saector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans r o ota Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators K -VA No. of Luminaires Swimming Pool Above ❑ n- El rnd. rnd. o mergency .�g tng Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. o tection an Initiatin Devices No. of Ranges No. of Air Cond. Toots No. of Alerting Devices No. of Waste Disposers at um Totals um_ er '" ons "'"....... ' " """"""""':" o. o 'e - ontatne Detection/AlertingDevices No. of Dishwashers ace/Area Heating KW Local ❑MunicipalEl Other Connection No. of Dryers ating Appliances KW [No. ecurity Systems:* No. of Devices or Equivalent No. o ea KW Heaters . o o. o Signs Ballasts Data Wiring: No. of Devices or ivalent No. Hydromassage Bathtubs of Motors Total HP telecommunications —a-ofDicer ui T No. of Devices or E uivalent 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: Inspections to be requested in accordance with NEC Rule 10, and upon completion. j 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 C$ BOND ❑ OTHER ❑ (Specify:) I certify, under the ains and penalties of perjury, that the information on this application is true and conwiete- FIRM NAME: oc. a I r Y Ci LIC. NO.: 2 0 571 A Licensee: 1 e' Yr j'' . id w i Signature� i'_✓ � F _�.._ ,_ . LIC. NO.: lG&y1;1-1S (Ifapplicable, enter "exempt" in the license number line.) Bus. Tel. No.: 978-995-LSBY Address: j713 "5}tr1ton Road IV. Shctrtta MA 01842- AIL Tel. No.: *Per M.G.L. c. 147, s. 57-61, scebrity work requires Departmentf public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one)❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ GS �,,,,,,� -Ok lb- G .,l � 1 //�, The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, Mass. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual) : t.TV Cu ccQocA% Address: 393 U'trl-'awe parK 0 ir-Nye City/State/Zip: Fo sie r C t iy C A U Y 0 Phone#: '999 X6 5- 2 y 97 Are you an employer? Check the appropriate box: 1. Y I am an employer with -0 4. ❑ 1 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. employees and have workers' [No workers' comp. insurance comp. insurance. $ required] 5.0 We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself [No workers' comp. right of exemption perm MGL insurance required] t c. 152, § 1(4), and we have no employees. [no workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. C Demolition 9. 0 Building addition 10. ❑ Electrical repairs or additions 11. 01 Plumbing repairs or additions 12. ❑ Roof repairs. 13. M Other Ad fe 16 1+<G ,, *Any applicant that checks box ttl must also fill out the section below showing their workers' compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. +Contactors that check this box must attach 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. --77 _ Co.Insurance Company Name: L u r I CV Yrl p r 1 CG n J. h$ u rG h CP C Policy # or Self -ins. Lie. #: W C g b7,3,L/4703 Expiration Date: t7/I ) Z 0 Job Site Address: 7 q v Fo r e s -f S+r, ei City/State/Zip: /1% /in d o i, 1e. M 13 01 By 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 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 $250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of perjury that the information provided above is true and correct. _Signature: Date: Print Name: r !Z o �,..�- Phone #: '993 - ?45- ?n g7 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 Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact person: Phone #: A6 �® CERTIFICATE OF LIABILITY INSURANCE D09/14IDD/Y1 09/14/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 0726293 1-415-546-9300 Arthur J. Gallagher & Co. Insurance Brokers of California, Inc., License #0726293 CONTACT NAME: PHONE FAX A/C No Ext: A/C No: ADDRESS: One Market Plaza, Spear Tower Suite 200 San Francisco, CA 94105 INSURERS AFFORDING COVERAGE NAIC# INSURERA: ZURICH AMER INS CO 16535 09/01/12 INSURED SolarCity Corporation INSURER B: LIBERTY INS CORP 42404 INSURERC: INSURER D: 3055 Clearview Way INSURER E: San Mateo , CA 94402 _ DAMAGE TO RENTED 1, 000, 000 PREMISES Ea occurrence) $ INSURER F: COVERAGES CERTIFICATE NUMBER: 23060847 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE INSR WVD POLICY NUMBER EFF MMIPOLICYY EXP MM DD LIMITS A GENERAL LIABILITY GL0967364403 .09/01/1 09/01/12 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR DAMAGE TO RENTED 1, 000, 000 PREMISES Ea occurrence) $ MED EXP (Any one person) $ 10,000 X Deductible: $25,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ A AUTOMOBILE LIABILITY BAP982931701 09/01/13 09/01/12 COMBINED SINGLE LIMIT 1,000,000 Ea accident BODILY INJURY (Per person) $ X ANY AUTO IX ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS X AUTOS PROPERTY DAMAGE $ (Per accident) $ B X UMBRELLA LIAB X OCCUR TH7661066265011 09/01/1 09/01/12 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10, 000, 000 EXCESS LIAB CLAIMS -MADE - DED I X I RETENTION$ 10, 000 $ A WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY �,/N WC967346703 09/01/1 09/01/12 WC STATU- OTH- XR S1 E.L. EACH ACCIDENT $ 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N❑ N / A E.L. DISEASE - EA EMPLOYE $ 1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Evidence of Insurance Evidence of Insurance Only ACORD 25 (2010/05) cbutz 23060847 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ,i,� a„ e ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Foix. intw ,stack A ong VI! Poforations COMMONWEALTH OF MASSACHUSETTS BOARD ELECTRICIANS E L REGISTERED MASTER ELECTRICIAN ISSSUES THE ABOVE LIGENSE TO.' 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TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that L �- has permission to performer7� wiring in the building of ......... .1.. * .... .. ........................................ at ..........?.7... ...� 75.s...........S. :orth Andover Mass. Fee..�s...'—. Lic. No G.......... ....E �rrc'rote (/ Check It tir ,k .0 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the X111 permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed forin. 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.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and maybe_deemed_by the, Inspector-of_Wires abandoned.and_invalid_ifhe—.. _ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. F-1 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 acri�o promote job growth and long-term economicl�acv4y And the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period be 'ginning on August 15, 2008 and extending"through August 15, 2012. 8 — Permit/Date Closed: ❑ Permit Extension Act — Permit/Date Closed: _L& *** Note: Reapply for new perp Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. t� 79 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 ININK OR TYPE ALL INFORI TION) Date. j/ J City or Town of: T13 o the Inspector of Wires: By this application the undersi ed gives no ' e of his or her intention to perform the electrical work described below. Location (Street & Number) '7/ -In ;-r Owner or Tenant ST(y,APT -#' L'/}W Owner's Address '74[`) fQ/?-rr,C Telephone No. 'W'7e C25—V4 Is this permit in conjunction with a building permit? Yes120*"- No ❑ BLDG PERMIT # Purpose of Building 0ULaUr4i 6 Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: UP 5T41 f� 1 1 X17 C!� ot�AC:C �CF�i�l1%S� A00 QC[ CiCP�T[= c2uguT C i1,Ct,�i i )cc70K- 14CAy- Completion of the following table may be waived by the Inspector of Wire.c. JDishwashers Recessed Luminaires uminaire Outlets uminaires eceptacle Outlets i witches s' anges aste Disposers ishwasherso. of Dryers No. of Water KW Heaters r No. Hydromassage Bathtubs OTHER: No. of Ceil: Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Above ❑ In- rnd. rnd. No. of Oil Burners No. of Gas Burners No. of Air Cond. Total Tons Heat Pump Number Tons KW Totals:................................................................. Space/Area Heating KW Heating Appliances ( KW No. of No. of Signs Ballasts No. of Motors Total HP No. of Total. Transformers KVA, Generators KVA o. of Emergency Lighting BatteEy Units FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Alerting Devices No. of Self -Contained Detection/Alertin Devices Local❑ Municipal Connection E, Other Security Systems:* No. of Devices or Equivalent Data Wiring: No. of Devices or E uivalent Telecommunications Wiring: No. of Devices or Equivalent Attach additional detail ifdes:red, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: f /C // Inspections to be requested in accordance with NEC 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: INSURANCEOBOND ❑ OTHER ❑ (Specify:) I cer7ify, under the pains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: - ,1C r6U,4Ajj0 LIC. NO.: Jq Se � C' Licensee: 6r IC: ptu ^ 0 Signature LIC. NO.:3ay 2- G 4 (Ifapplicable, enter "exempt" in the license number line.) Address: 41<76 MtIMMrjtea &p# JDC-RCU " /"ABus. Tel. No..-. 7W Z� *Per M.G.L. c.147, s. 57-61, security work requires DepAlt.Tel.No.: Q artment of Public Safety "S" Li cen 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) Elowner Owner/Agent ❑owner's agent. Signature Telephone No. PERMIT FEE. ,$ ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL 4. INSPECTION — SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - ( ] Inspectors' comments: (Inspectors' Signature - no initials) Date -�• Jul OKL'1_11V1� - V1t71LtC: 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 THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. Ae Commonwealth of Massachusetts Department oflntlustrialAcciclents Office ofInvestigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: ]3uilders/ContractorsfElectriciansJPluxnbers Please Print Name (Business/Organization/Individual): `�I t �- 11 f Address: W 6 M AM Mat 14 City/State/Zip: ©CC 9Cu'r. �1.,* C D� � � Phone #: �„� � b�' � AA Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. New construction employees (full and/or part-time) .x 2.� I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. s 7. ❑Remodeling . ' ship and have no employees These sub -contractors have 8. ❑ Demolition workingfor me in an capacity. Y9. workers' comp. insurance. Building addition - [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also flI 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. lContractors 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 isproviding workers' compensation insurance for my employees Below is the policy andjob site information. Insurance Company N Policy # or SeIf-ins. Lic. #:. Job Site Address: Expiration Date: 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 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un der the pains andpenalties ofperjury that the information provided above is frue and correct. Signature: Date - Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Perm!Mcense # Issuing Authority (circle one): 1. Board ofHealth 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other 11 Contact Person: Phone #: 11 FIXTIIRFS MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: � , MA. Date: / Permit# �D�5� Building Location: Owners _ DEDICATED Type of Occupancy: CommercialE] ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential [✓� ` New: ❑ Alteration: ❑ Renovation: [j Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTIIRFS - 1,nes that INSURANCE CO' has Perrnis I have a current li: p�Um s'on to Perfor S 7 'LX es 2/No ❑ If you have checl b'n9 In the b m ' e!p U o� �'� at. fcP,d Ings of A liability insu F OWNER'S INSI Lie No. �' apter 142 of the Massachusetts Check # North Andover, /•Mass. Signature of C PluMB1 NG 1 NSPEC OR� I hereby cert urate to the best of my Knowledge a...._� . pliance with all Pertinent provision of tne,..__, By Type of License: - Title ��i'Masterumber Signature oT City/Town[:]Journeyman License Number: APPROVED (OFFICE USE ONLY) DEDICATED Z SYSTEMS En 0 Uj w W Z O W N 1 Z Z LA Ln knW Z ~ Y _ Q W Z V1 C ~ w H Z 'n Q H CA = 'y' w a H Z O a ~ p Q Q p Q C' � W Q Q O 'n LM Q Ln Z W_ O Q W Z Vf W J Z OC C LL oif . O W a Y = 2 0 0 o o>> Z Q Li o= a o Y Z Q Vf Uj LU F F W a a a u Q a } F a co go 0 3 SUB BSMT. BASEMENT 15T FLOOR 2ND FLOOR 3RD FLOOR 4T" FLOOR ST" FLOOR 6T" FLOOR 88,8 ° 7T" FLOOR 8T" FLOOR Installing Company Nar o- � NORrh � Date J �•/r � Addresslp1C%a�u • * • A �; T•OwN OF Business Tel: Name of Licensed PI • ;� �s'•..�; �^ •'• This _ N OR TH PERM►T N FOR PCU DOVER MDINn - 1,nes that INSURANCE CO' has Perrnis I have a current li: p�Um s'on to Perfor S 7 'LX es 2/No ❑ If you have checl b'n9 In the b m ' e!p U o� �'� at. fcP,d Ings of A liability insu F OWNER'S INSI Lie No. �' apter 142 of the Massachusetts Check # North Andover, /•Mass. Signature of C PluMB1 NG 1 NSPEC OR� I hereby cert urate to the best of my Knowledge a...._� . pliance with all Pertinent provision of tne,..__, By Type of License: - Title ��i'Masterumber Signature oT City/Town[:]Journeyman License Number: APPROVED (OFFICE USE ONLY) The Commonwealth of Massachusetts r hF Department of Industrial Accidents 1 Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Prinf Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: q 7L- SIU — 30 Are you as employer? Check the appropriate box: 1. ❑ I ama' employer with 4. ❑ I am a general contractor and I IIployees (full and/or part-time).* have hired the sub -contractors 2.in 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 ain a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.0 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 are 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 acid 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. #: Job Site Expiration Date; 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 Sedtion 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 theI�'i�or insurance*coverage verification. I do hereby c of oeo the pails and penalties of perjury that the information provided above is true and correct' rAV 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' compensationaffidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone numbers) 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 Y employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmationof 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 pen-nit/license number which will be used as a reference number. In addition, an applicant that must submit multiple,-pen-nit/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 pen -nits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pen -nit 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 Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia x IN PLUMBERS AND GASFITTERS LICENkE R ,pT&SAe6RM Tf.�,PLUMBIE .NICHOLAS P SAVVAS 1259 OAK ST ,,.METHU-EN MA 01844-5216 nr%/ni/i7 zZal Z6 UnNi9joijF Mj I It MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print it Type) _Mass. Date ZCc�� Permit #, ;) Building Location: —Z {^� 4 owners Name �J G Type of Occupancy �I- New O Renovation ElReplaclent 2"�ns Submitted: Yes ❑ No ❑ P z U FIXTURES Installing Company Name, "M 0;'N�"r, Certificate Address �� 1 r ' ; ; •.': Business Telephone,_ Name of Licensed Plumber hdspP �P�ffe TO i d � INSURANCE COYERAGI' a A,4�6 'ssi s char �O I have a currennt�labilt �� °o F �+0 ` ) I Yes Q' '��P ��'rhe t°pPrf ilii � 09�, \ It you have checked ch • . G ^ � • c 6G,Io' • °rid � 0,9 y,4 • ? A liability Insuranc S eco ��� ?^S gs°f s� A�G00` c` - OWNER'S INSURANcE Fq Chapter 142 of the Mass. Ge-'� ' Signature of Owner or Owner's Agent I hereby certify that all of the details and information t h A `� . ^�10 knowledge and that all plumbing work and •installations�G <I -h9 f my pertinent provisions of the Massachusetts State Plum Metic .Opp°` all 44 Title e re or Ucensed M4 FC' 09 ass City/Townm Type of License: Master APPPDVEUMTF• i N license Number L 3 j N O Z W N 2e Z N j N > d V = < F W Z O O C7 H G O J N _W y M N W = N Q V C W N N Y { N W Z SF a 3 X G} C _. W C m C H y < }. H z C d V < < O W W f- Z V < ; H ►� W O 3 S Q Z d. O Z Z W. w X W `s 3 ti H o a a m o SUR--6SIIT. BASEMENT IST FLOOR I Ir 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR ` 6TH FLOOR 7TH FLOOR s STH FLOOR Installing Company Name, "M 0;'N�"r, Certificate Address �� 1 r ' ; ; •.': Business Telephone,_ Name of Licensed Plumber hdspP �P�ffe TO i d � INSURANCE COYERAGI' a A,4�6 'ssi s char �O I have a currennt�labilt �� °o F �+0 ` ) I Yes Q' '��P ��'rhe t°pPrf ilii � 09�, \ It you have checked ch • . G ^ � • c 6G,Io' • °rid � 0,9 y,4 • ? A liability Insuranc S eco ��� ?^S gs°f s� A�G00` c` - OWNER'S INSURANcE Fq Chapter 142 of the Mass. Ge-'� ' Signature of Owner or Owner's Agent I hereby certify that all of the details and information t h A `� . ^�10 knowledge and that all plumbing work and •installations�G <I -h9 f my pertinent provisions of the Massachusetts State Plum Metic .Opp°` all 44 Title e re or Ucensed M4 FC' 09 ass City/Townm Type of License: Master APPPDVEUMTF• i N license Number L 3 m m m