HomeMy WebLinkAboutMiscellaneous - 77 MILLPOND 4/30/2018r
N
J
Q
W
b
0
0
b
� 9701
Date ....�P... !-5-- �.6��.....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
�•�Ss^c�au5�
This certifies that ............ .....yPCt1/...............�.Tl �..............
has permission to perform...........5, E/2U1 Lt %'U4
.................................................................
wiring in the building of ........................................................
L orth Andover, Mass.
at......................%................................................
Fee... r$ � ��.�.'7 Lic. Noc2.bra.f C .......... .IA
......
ELECSPE r6R
Check #
LIU111111W/yffWal ff UN
Permit No.
Department of Fre Service
- Occupancy and Fee Checked
�M BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank)
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 EV INK OR TYPE ALL INFORMATION) ]Date: _ M, H 1 9 O 10
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) 1 1 ?O h ok
Owner or Tenant yy p' Telephone No.q`1$- h-�1��
Owner's Address k C Sht 1, �F
Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box)
Purpose of Building te41�o,,� ` ( oAd0� UtilityAuthorizatibnNo. 9S95,7.33
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: 'ly►s4411 new iso QWjQ Vha%r 6tftkef-, Mgr r
cojetion nfthp following table may be waived by the Inspector of Wires.
-Attach aawttonat aerau Vaestrea, ur as requ-8a uy uce �c �yr��, .•
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in'force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ,Q BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains andpenalties of perjury, that the information on this application is true and coniptete.
FIRM NAME: LIC. NO.:
Licensee: 'D0 h#i1d ._5 y a r,P_ Signature LIC. NO.: 20,5 1 P`
(If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: LS90 _-�Ml
Address: 7_s LArwYe a 2A \ �f9`��+u.�v�� t\'A'A 0 12, 44 _ Alt. Tel. No.:
*Per M.G.L c. 147, s. 5741, security work requires Department of Public Safety "S" License: Lie. 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.
No. of Total
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
AboveIn-
Swimming Pool rnd. ❑ grndi
o. o mergency ig mg
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Detection and
No. of Switches
No. of Gas Burners
Initiatin Devices
No. of Ranges
No. of Air Cond. Tons
No. of Alerting Devices
HeatPump
Number
Tons
KW
No. of Self -Contained
No. of Waste Disposers
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 WaterKW
No. of -No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or E uivalent
Telecommunications Wiring:
No. Hydromassage Bathtubs
No. of Motors Total HP
No. of Devices or Equivalent
OTHER:
__i
-Attach aawttonat aerau Vaestrea, ur as requ-8a uy uce �c �yr��, .•
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in'force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ,Q BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains andpenalties of perjury, that the information on this application is true and coniptete.
FIRM NAME: LIC. NO.:
Licensee: 'D0 h#i1d ._5 y a r,P_ Signature LIC. NO.: 20,5 1 P`
(If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: LS90 _-�Ml
Address: 7_s LArwYe a 2A \ �f9`��+u.�v�� t\'A'A 0 12, 44 _ Alt. Tel. No.:
*Per M.G.L c. 147, s. 5741, security work requires Department of Public Safety "S" License: Lie. 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.
,0 , �
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
4 s�• www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): o} w Tcwl,ja.e,
Address: 9S
City/State/Zip: \4,e,4„4.fv, \114 t� O I N !A Phone #: —<� 10 —99 6 a -
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.KElectrical 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 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. Lie. #:
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 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 cert/ fy rfnder thep*s andpenalties ofperjury that the information provided above is true and correct.
Phone #• 91% - 5I l3 -Lm a
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 #:
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
NO.ANDOVER , MA , Mass. Bate tg Permit #2U ,7 y -"-
Building Location 72 MILLPOND Owner's Name
NO . ANDOVER, MA Type of Occupancy RES
G
New ® Renovation ❑ Replacement ❑ . Plans Submitted: Yes❑ * No ❑
Installing Company Name CALLAHAN AIR CONDITIONING Check one: Certificate -
Address 91 BE .MONT STREET 13 Corporation
NO . ANDOVER , MA . 01 8 4 5 ❑ Partnership
Business Telephone 508-689-9233 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter JOSEPH KEVIN CALLAHAN
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes Q No ❑ '
If you have checked Les, please indicate the type coverage by checking the appropriate box.
A Ilablllty Insurance policy ZI Other type of Indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General laws, and that my signature on this permit application waives this requirement.
Check one:
awnerD Agent C3Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) In ove application are true and accurate to the best of my
knowledge and that all plumbing work and Installations performed under the permit sued for this applicaWor
In plancs with all
pertinent provisions Of the Massachusetts Stale Gas Code and Chapter 142 of the neral Law
BY
Type of Ucense: 4 -Ir k=iAWA
Plumber gnatur o c nse um titer
Title Gasfilter
Master License Number M-3440
City/Town Journeyman
Af rrrJ'/t p
N
N
N
Y
T
s
U)
N
Q
N
N
R
V
O
O
N
=
i-
Xl
W
W
N
Q
Uj
O
U
m
)�-
=
n
`
c7
'�
G
<
m
H
tom-
`t
o°
at
C
-
O!
=t
¢
N
C7
2
ur
V
6
W
=
N
=
W
F-
<
yr
CL
�'-
Q
>
W
=
W
P,-
J
<
�•
W
S
W
G
O
tsr
?
Lt
W
)-
W
J
H
)j....
Q
V
<
W
>
Q
W
7
<
}r
D
<
C7
<
J
O
0
O
O
c¢
W
>
Q-
O
O
O
0.�
N
O
rL
S
O
V
S
U.
O
SUB—BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
I
4TH FLOOR
STH FLOOR
I
6TH FLOOR
I
I
7TH FLOOR
STH FLOOR
Installing Company Name CALLAHAN AIR CONDITIONING Check one: Certificate -
Address 91 BE .MONT STREET 13 Corporation
NO . ANDOVER , MA . 01 8 4 5 ❑ Partnership
Business Telephone 508-689-9233 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter JOSEPH KEVIN CALLAHAN
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes Q No ❑ '
If you have checked Les, please indicate the type coverage by checking the appropriate box.
A Ilablllty Insurance policy ZI Other type of Indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General laws, and that my signature on this permit application waives this requirement.
Check one:
awnerD Agent C3Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) In ove application are true and accurate to the best of my
knowledge and that all plumbing work and Installations performed under the permit sued for this applicaWor
In plancs with all
pertinent provisions Of the Massachusetts Stale Gas Code and Chapter 142 of the neral Law
BY
Type of Ucense: 4 -Ir k=iAWA
Plumber gnatur o c nse um titer
Title Gasfilter
Master License Number M-3440
City/Town Journeyman
Af rrrJ'/t p
r'
%TQ2034Date .1... !�,�` b'........ .
! 1-
CF
,ORT" TOWN OF NORTH ANDOVER
`p PERMIT FOR GAS INSTALLATION o
i'
This certifies that ... Gt L 4� P.1-1 ....... ......... .
has permission for gas installation ..P % t� /. s
g
in the buildings of . ..................
at.. 7..,fz� ! ! .%gip Z. ....... , No h Andover, Mass:
Fee.. �? �..... Lic. No..3 .y 5! U .. . ......
SINSPECTOI
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
1
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTINO
(Print or Type)
NORTH ANDOVER Mass. Date '�e; Z P 'C? G
kuilding Location j22jL_ ,00/Z0 Permit 2 LJ
%V. f-�/�OdLP1L /724. Q✓,r Owners Name
?Joy F"eR'c77PQefe 6
New Renovation D Replacement Plans Submitted D
FI XTURFS
(Rrint or Type) CE;eck one: Certificate
Installing Company NameA09PM, ze&v"�f - 10(01'rJ,e"'(v Cr- P.
Address �'� ?LLi /> 1-46E RLY. — �� Partner.
Business Telephone:
Name of Licensed Plumber or Gas Fitter %Rk
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy Aid Other type of indemnity Q Bond El
lnsura ce Waiver: 11 the undersigned, have been made aware that the licensee of
this plication does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner 11 Agent M
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under' Permit iueed fo: this application will-be4n eomplianoe with &II pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of tho General Laws. ..
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICENSE:
FU Plumber
Gasfitter Signature of Licensed
Master Plumber or Gasfitter
Journeyman P -f
9License Number
=ME
MEN
MENEM
MEMMENEE
OEM
MENEM
ME
�iriiiiiiii
iiiiiii�iiii'
(Rrint or Type) CE;eck one: Certificate
Installing Company NameA09PM, ze&v"�f - 10(01'rJ,e"'(v Cr- P.
Address �'� ?LLi /> 1-46E RLY. — �� Partner.
Business Telephone:
Name of Licensed Plumber or Gas Fitter %Rk
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy Aid Other type of indemnity Q Bond El
lnsura ce Waiver: 11 the undersigned, have been made aware that the licensee of
this plication does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner 11 Agent M
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under' Permit iueed fo: this application will-be4n eomplianoe with &II pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of tho General Laws. ..
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICENSE:
FU Plumber
Gasfitter Signature of Licensed
Master Plumber or Gasfitter
Journeyman P -f
9License Number
do --
TO 2225
,gypRTS,ot
0
13
Date-
TOWN OF NORTH ANDOVER R
PERMIT FOR GAS INSTALLATION 8
ti
This certifies that ..........................
has permission for gas installation 5'. Af. F
in the buildings of .. rr ....................
at ;7
r.
.......I . North Andover, Mass.
Fee?...'...Lic. No../.(.. ......
GASINSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File