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HomeMy WebLinkAboutMiscellaneous - 75 EMPIRE DRIVE 4/30/2018--- -- - -- r 9178 Date .. Ahk . . TOWN OF NORTH ANDOVER o PERMIT FOR PLUMBING This certifies that ....../ ......9CihrS/... .............. has permission to perform ..lMp. /to. .. .................. plumbing in the buildings of.. G?r.' Q'' r%!�L-.. .�. . I� at ... ................ , Nqvth Andover, �Mass. Fee,3�5?,L Lic. No../4.?.`�ty 7�/ 7/ PLUMBING INSPECTOR Check # C\ POWNER TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY ys t� c�s2_ MA. DATE I I - rt Lf PERMIT # JOBSITE ADDRESS Jir 1�1'1/lr i71(� Q1 L _tz_ OWNER'S NAME Ul C ADDRESS TEL FAX OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL NEW.- RENOVATION: ❑ REPLACEMENT: ElPLANS SUBMITTED: YES ❑ NO ❑ FIXTURES Z FLOOR— BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIUSAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ( Z ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which, meets the requirements of MGL Ch. 142. Yes ["No ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY V 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 BOX ONLY: OWNER ❑ AGENT ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and iriformation I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Ch ter 42 of General La s. PLUMBER NAME STEP0150 C. GALIPSKY SIGNATURE LIC # 03103 MP E�' JP ❑ CORPORATION A 3196 PARTNERSHIP ❑ # LLC ❑ # COMPANYNAME GAuNSKY PLgmgjNb *- gyAT71JADDRESS: P-0. QQX 1701 CITY t•IAVERItit,t; STATE rn•A- ZIP 01'631 EMAIL www. mrp1Vmbef( AQ1, Caws TEL COV- 37q- 1714 3 CELL 508- 50c1 - .SgOH FAX q7$- 3�1- k13i Date. ............ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that has permission for gas installation.,—/44/. C4�-- ..4 .. ........... in the buildings of ZI ................. lf,e, at ... No:rYthndover M S. Fee..Lic. � 1, 00. -0,0 GAS INSPECTOR Check # _-7476 7885 It GOWNER TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: MA. DATE -1 I - 3 - (1 PERMIT # JOBSITE ADDRESS:_ -7 f (S 01 rc, Q f I -e— OWNER'S NAME:(,)'2r- RSI N,8 V iLG(06! LCC, ADDRESS: TEL: FAX: OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL`®' NEW:W RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCESZ FLOOR- Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY g OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this applicatio will be i mpliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME:_ STEPHEN C G A L I NS KY LICENSE # 10 a 4 tr SI ATURE COMPANYNAME: CALW3K`1 PLWAINJOG + ADDRESS: P.O. c)Ox 1,701 CITY: 9AVE-2HIL 1 STATE: rn.A. Zip: 01831 FAX: q78- Gal -8131 TEL: 979- 37y- 1743 CELL: 50C - 50q- Sgoq EMAIL: www. mrplumbefff MASTER [j JOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION V# 3196 PARTNERSHIP ❑ # LLC 0 # W H O z z 0 H U W a d w ❑ a z z o V)rlCD �- w � ~ w o o uj H r z LLI 3 ¢ a w LLIW P4 O w w V a c7 0 d a H�y W J H � d Q 69 N 6i 2 W H LL- C/] W H 0 z z 0 H U W a d t7 D O a Q IN Date.A ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING - This certifies that ... .......... has permission to perform .... ........ ....... /X: ........... .......... wiring in the building of ...... ........ ................................. at........ orthMdover,m S. Fee ....7 ..... Lic. No. ................ .......... LECTRICAL INSPECTO Check #/2--1 10502 `4 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No./ Occupancy and Fee Checked :ev. 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 PRINTININK OR TYPE ALL INFORMATION) Date: // - 23 —/ / 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) %r 0 �7— d 73, /� e • - /%� _ Owner or Tenant ff, Owner's Address Z 7 w Is this permit in conjunction with a building pefmit? Yes Q/ Purpose of Building No ❑ Telephone No. vG (Check Appropriate Box) Utility Authorization No. Existing Service AiZps / Volts Overhead ❑ New Service yU(/ Amps j-1- / 2Yv Volts Overhead ❑ Number of Feeders and.Ampacity Undgrd ❑ No. of Meters Undgrd �No. of Meters Location and Nature of Proposed Electrical Work: /,,i, . �/� w �wy s Com letion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: 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 nd. rnd. o. o Emergency Lighting Batter Units Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS Nc. of Zones NO..Detection and No. of Switches No. of Gas Burners Initiatin Devices No. of Ranges No. of Air Cond. Tootal No. of Alerting Devices Heat Pum Number Tons KW No. of Self -Contained No. of Waste Disposers p Totals: _........................... - Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal E:1 Other Connection No. of Dryers rS' Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts . No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wtres. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: //- Z 3 -// 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 Dff6ND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: f s G t-1, - LIC. NO.: 3 Licensee: ,,X, Z-- Signature LIC. NO.: _ (If applicable, nter "exempt " in the license number line.) Bus. Td. m-: 0 Z - 7--< - 3 Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Departmen 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 -El owner's agent. Owner/Agent.T.,PERMIT FEE: $ c:at.,vp Telenbone No. 2 The Commonwealth ofMassachusetts Department of Industrial Accidents 4 tin Office of Investigations '� i 600 Washington Street gto t Boston, MA 02111 www.riiass goWia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/organization/Individual): Address: City/State/Zig: Phone #: . re you an employer? Check.the appropriate box: :n employer with 4, ❑ I am a general contractor and I F29-El Type °f prgject (required): employees {full and/or part-time),* I am .a.sole have hired the sub-contractors6• listed ❑ New construction �• proprietor. or partner- on the attached sheet.1 ❑ Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition working for mein any capacity, [No workers' comp. insurance p workers' comp. insurance. 5. ❑ We are a corporation and its 9, ❑ Building addition required.] 3. ❑ I dm a homeowner doing officers have exercised their 10.0 Electrical repairs or additions all work right of exemption per MGL 11,❑ Plumbing repairs or additions myself, [No•workers' comp, insurance-required.]t c, 1.52, § 1(4),'and we have no 12.❑ Roof repairs employees, [No workers' 13.❑ Other comp. insurance required_] t HoHo applicant that checks bob# l must also fait out the section below showing their workers' bompensation meowners who submit this af[idavit Ifthey are doing policy information, 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 nEme of the sub -contractors and the;, workws' comp. policy wbr mation. I amara eaasployer that E5}Yr®&ZdBFdg:FU®rlleP iinformation.s — eo?Apensadol1 dfzsurajwefortit ? eFtPloyees: Below is thepolicy randjob site Insurance Insurance Company Name: ' Policy # or Self -ins. Lie.. #: Expiration Date: - ' Job Site Address: City/State/Zip: Attach a copy of the worke.rs'.'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- fiine 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 under the pains and penalties of perjury that the information provided above is true and correct Signati re: Date: Phone #: Official use only. Do not write bi dr is area, to b2 c,,,,.,pr&,ed by city or tow;;. official City or Town: _ Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector b. Other Contact Person: Phone #• Fur U) m m m m m EP m "L v y d C n CO2 CM) Z y C'0 � r � � o CL = y CD CDCL o s cr ` =r ftG CD CSD O CSD C CD cop) av y cQ CD � v CO2 O 1 Z O O O C CD CD wop O' .44 o Swa c 2EEL y �_ »Ma m o NS?CLc m s O p. .°?. �' y T CO SOON p m � a ,p NO CD Om ..w O O .� =r .A �• M CN Q CL 330'p E: �_ Crn^ `� � ? VJ O m m N b �om�iiiQQQ a OC N CA 01 Y' Z H a m � � o' M. cn co CD ca m CT to OO cn W O CD • cn W pq G7 E m C. r ? cl W ,\ dc m d s trJ i C p M. x� r. S. rt ' M1Fy���y � hh►//1ii.�i r � �yy Fi � I" �..t 7 O ! \ W LAWRENCE .H. OGDEN, IP IE .498:EAST MAIN STREET 978.352-8318 fax 978 —352-2858 celh 978-502--5921.