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HomeMy WebLinkAboutMiscellaneous - 776 GREAT POND ROAD 4/30/2018N Date ......x..`..1...5....F7 TOWN OF NORTH ANDOVER PERMIT FOR WIRING NCH54t This certifies that aw z ......... ... ........ .................... has permission to perform ....... ; ................ ........ .. wiring in the building of ................ at .....7.7(,,o Aqrth Andover, Mass. 7'**'*'*"** ''Fee......0........... Lic. No4 ............... . q ....... .... .............................. i . 7-6v",< ELECTRICAL I .... . ..... Check e 1309?1 I Commonwealth of Massachusetts Department of Fire Services 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 NK OR TYPE ALL INFORMATION) Date: c2 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intqgtjon to perform the electrical work described below. Location (Street & Number) Owner or Tenant 5, (JO r- � 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 New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ Undgrd ❑ No..ofMeters Overhead ❑ Undgrd ❑ No. of Meters Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed LuminairesNo. 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 E] In- EJo. rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: I 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 KW 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 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 anti complete. FIRM NAME:. �a—`i®.�J 1L— LIC. NO.: S b Oyt Licensee:�� �, } �} Signature LIC. NO.: —9_ & �3 & (If applicable, enter "exempt" in the license number line.)!� Bus. Tel. No.•9? Address: �'. .4 51z ��— !�� rv- n .:5'%�� eJ /J A Alt. Tel. No.:4 z-3 --6 crJ - 2� *Per M.G.L c. 147, s. 57-61, security work requir s 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 PERMIT FEE: $ Signature Telephone No. ❑ 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 of ongoing construction activity, and may be deemed by the 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 extending -through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass R Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPE T N: Pass Failed L<' Re- Inspection Required ($.) ❑ Inspectors Commen Inspectors Signature: Date: FINAL INSPE TION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature:Date: S DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com } Irl y The Commonwealth. of Hassachusetts Department of industrial Accidents Office Oflnvestigations 600 Washington Street .Boston, MA 02111 www .mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contraci Auulicant Information Name (Businesslftanilzaiion/individual): � � yy�-� t �/►'l�r �, l cTy- z v Address: —` City/State/Zip: / fad 4o^) < V k t% Are you an employer? Check t e appropriate box: Type of project. (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and 1 6. EJ Now construction employees (full and/or part-time).* 2.E] 1 am a sola proprietor or partner have hired the sub -contractors listed on the attached sheet. `!- ❑Remodeling ship and'haveno.employees These sub -contractors have 8. [] Demolition wonting forme is any capacity. workers' comp. insurance, g, (1 Building addition DNo workers' comp. insurance S. ❑ We area corporation and its 10.❑ Electrical repairs or additions ` required.] 3111 am a homeowner doing` all work officers have exercised.their right of exemption per MGL 11. [( Plumbing. repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roofrepairs insurancerequired.] i [No em to eeso woers' p Y I311Other comp. insurance required.] NAny applicant that checks box#1 must also fill 6utthe section bel6w showingtheir Workers' compensatioapolicy information. i Homeowners who submit this affidavit indicatingthey aiie doing allworlt and then hire outside contractors must suhmit anew affidavit indicating such. TContractors that cheAthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that isproviding workers' comnpemasation insurance for mny employees Below is thepolicy andJoh site infomation. Insurance Company 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 requiredunder Section 25A ofMGL o. 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 civill penalties in the form of a STOP WORD ORDER. and a flue pfup 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 AIA. for insurance coverage verification. X do Hereby gertify under the p^ andZenaltiev ofperjury thtit the information provided alcove is true and correct, Phone #• `1 7 � " � •� � — c' � J f� Official use on1y..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. CitylTown Clerk 4. EIectrical 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, ox any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a:deceased employer, or the redeivex or trustee of au individual partnership, association or other legal entity, employing emptHwver theoY owner of a dwelling house having notmore 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 Ideal 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 insurancecoverage 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 ofpuhlic work until acceptable evidence of compliance with the insurance requirements of this chapterhave beenpresentedto 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 (q), address(es) and phone numbers) along with their cerUcate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the arry members or partners, are notrequired to cworkers' compensation insurance, If an LLC or LLP does have employees, a policy is required. B e advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain, a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their Self-insurance license number on the appropriate line. City or Town Officials Please be sure thatthe affidavit is complete andprinted legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be -sure to fill in the permit/license number which will be used as a reference number, In addition, an applicant thatmust submit multiple permit/license applications in any given year, need only submit one affidavit iudicating current policy information (ifnecessary) and under "rob Site Address" the applicant should write "all locations in (city or town)." Acopy of the affidavit that has been officially stamped ox 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 mast be filled out each year. Where a home owner or citizen is obtaining a license oxpermit 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 aid fax number: `fhe Com monmaltbLofM ach�SP s - Degax e t Qf TadusWal A,coidenta ofte OffAVQStfgaA0XW 6,00 "Qt�astg�o�. �xe�t Boston, IYU 02111 TQ1, ## 617-721' -4900 Q#406 ox 1-877,MMSAM Revised 5-26-05 Fax 0 617"727'7749 ' wwtv.x.�as�,go-��claa GOMMOMALTH OF MASSACHUSETTS. r BOARD Of - ELECTRICIANS:, =F� ` � t, THE FOLLOW IISSUES NG.'L i CENSE �¢ F AS; A.12EG J{�UFtNEYMAN EC- ,I Q'N"'�: ,a •' RMIE,1; B EATON, !, KI csTON NH 03848-3q5 ISI N 6:5`07f 31 b 10 10514 2645 ,xr /.;] n Y. o COMMONWF-ALTH OF MASSaG US TTS -, • OF V . t C�rR I c 1 ,SSUES THE -FOLLOWING 'L I CAN E AS A k RGtITFRt D MASTER ;ELECTRr1' IC AN";Vu DANIEL B EATON_*�'y'` z k 5 CHASE ST' LuNGSTON * Nl 03848 300_' 0h4R'.'x 1:::1 b 1010 Date ...... ..... 14.05 .............. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ............ . . ..... ...................... ........... 6 .................. , -/ �.Q 0 has permission to perform ................... ...... cls ...... cl�lv�.IQA ...................... ...... ................ ........... plumbing in the buildings of ....u3NO4 .. (..`e.,)......................................................................................... at .... .......lel- ...... lel-_x .... North Andover, Mass. Fee.............. ........ Lic. No. ........ �................................. e ............................... PLUMBING INSPECTOR Cqeck # v),- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY- ._._.el MA DATE .{ PERMIT # JOBSITE ADDRESS m7 _� i'�� /4► . II OWNER'S NAME jr OWNER ADDRESSONd - ! TEL /4,0�_ I TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: 19/ REPLACEMENT: 0 PLANS SUBMITTED: YES 0 NOD FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 C BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM€ DEDICATED GRAY WATER SYSTEM (._ _.r I I { ' { (Y_ (J I _ (_ f ...I f f _ DEDICATED WATER RECYCLE SYSTEM _ (_._-____J _____.. f ....__J .__ ! ► f -= __ _.—S. —_! ___1 DISHWASHER ___ -= 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN (___� ___-_( _____.J _....__ [ _._� _.__J .�_._.1 _ .__._! ._._._.._f ___ ___€ ..____ _ € __.__.___I t• INTERCEPTOR (INTERIOR) _j __..__.! .____1 KITCHEN SINK— LAVATORY ROOF DRAIN SHOWERSTALL SERVICE / MOP SINK ( I ! -__-.( —1 —. ( J I TOILET HE f O URINAL WASHOG MACHINE CONNECTION I s ' i € E ! ' WATER HEATER ALL TYPES } WATER `PIPING i I ! i OTHER — INSURANCE COVERAGE:_ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES R' -/NO 0 cT IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW u LIABILITY INSURANCE POLICY ! OTHER TYPE OF INDEMNITY 0 BOND OWNER4 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 0 AGENT �] SIGNATURE OF OWNER OR AGENT I 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 application will be in liance ertinent o isi f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMEQ � _ LICENSE # SIGN RE MP [R/ JP N 0# J PARTNERSH 0# t LLC EDP COMPANY NAME �(,uM/g ADDRESS CITY011 STATE ./q �] ZIP O' ` �, TEL FA r6 9-f Z CELL Q76 3 bl.-br.. AIL d fMM .. - - ..------- --— -- -- -- - - . O U a r %y � ti • z El N O F— rrl O W O CL Z U)® � a w co a w a in p o a' W Q C4 v J a a. cf) w z w s- a W z d z O U W 1 The Commonwealth of Massachusetts Department oflndustdglAccidints Office of Invesfigations 600 Washington. Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Cont°actors/Electriciians/Plumbers City Phone #:7SZ-- 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 listed on the attached sheet. t 2. Lei Iam a sole proprietor or partner- / s�p 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 3111 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.] ► employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7,�Demolfflon emodeling 8. 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i -Homeowners who submit this affidavit indicating they ae 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. Yam an employer that is providing workers' compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name:.e4."f%� Policy # or Self ins. Lie. Expiration Date: Job Site Address: 771 6< P cs&d 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 maybe forwarded to the Office -of Investigations of the DIA for insurance coverage verification. I do that the information provided above is true and correct. 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 ofhire, 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 ofpublic 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 au LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents fox confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain, a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. ' City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be -sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submitmultiple permit/license applications in any given year,.need onliLbmit one, affidavit indicating current policy information (ifnecessary) 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 Ince 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 a'hd fax number: ! �4 `rho Commonwealth of M•assa.,chusPtts Depafta,utofIndustrial ,A.ccidopt6 Ofte ofinvestigatignj% 600 Washington Street Boston, MA02111. Tei, # 617-22,' -4900 at 406 ox 1-87.7 MASSAkB Revised 5-26-05 Fax 0 617-727-7749 v+tt�vt.z�,ass,g¢v�ciia PLUMBEttS,: 41':N'U SS UES THE FOLLOWIB' LjCENSE g AS A MASTER P,L'UFBE,R L I CNSED JAMES J MACGILVRAY �, 2A PR'IRC.ET,. tF fir} a r: n1NA 01:923 143..3. �'.�pVERs 29419 13A 0-'/0111116 4+ PLUMBEttS,: 41':N'U SS UES THE FOLLOWIB' LjCENSE g AS A MASTER P,L'UFBE,R L I CNSED JAMES J MACGILVRAY �, 2A PR'IRC.ET,. tF fir} a r: n1NA 01:923 143..3. �'.�pVERs 29419 13A 0-'/0111116 , �-C� This certifies that. . ?�a� .............. has permission to perform . . ....... plumbing in the buildings of ... .................. at 71 -1 .(10 G-( . Q-0-4- *RA' Q' 44orth Andover, Mass. 2-0 Fee. Lic. No. PLUMBING INSPECTOR Check # r1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK; - CITY /'V _�! MA DATE ( PERMIT # W44 w'L O JOBSITE ADDRESS % OWNER'S NAME POWNER ADDRESS _ G -f _^I TEL R%i FAX _ j TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL 93 PRINT CLEARLY NEW: Q RENOVATION: 53 REPLACEMENT: 0 PLANS SUBMITTED: YES E9 NOD FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB_I CROSS CONNECTION DEVICE _.! ._....___ I •__.. _._..___._.J .. ____..: ) _ _._.4 _..._._..w. _..__.._! _..� __i _.__-._.: _T I I I DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES ATITAI :771�Ii•[e INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES D NO El IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ©I 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 01 AGENT 0 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 application will be in compliance with all Pertinenj�rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. " /7 & // PLUMBER'S NAME / % r _ .., %'l✓ _ I LICENSE # SIGNATURE MID JP 0 CORPORATION 0# - j PARTNERSHIP# LLC COMPANY NAME j � _ ADDRESS 3 ie LAW� CITYJi1 �� ... - STATE ZIP �� �.._ .. I TELL17 FAX t CELL �� EMAIL ..I, -l', I , I •I The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA. 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Q Please Print Legibly [dame (Business/Organization/Individual): � � s t Jti'46 Address: /5 tree ,OCAS City/State/Zip: M p.p P, Phone #:, .re you an employer? Check the appropriate box: ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors I am a sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have working for mein any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ❑ 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. F1 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other y applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. )meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ttractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. n an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site wmation. .trance Company Name: t:�__T icy # or Self -ins. Lid. #: Expiration Date: Site Address: t— N'LQ fid jq t1 City/State/Zip:%i/- t ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 p to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Istigations of the DIA for insurance coverage verification. hereby certify under the pains andpenalties ofperjury that the information provided above is trite and correct. tature: Date: lfficial use only. Do not write in this area, to be completed by city or town official. :ity or Town: Permit/License ;suing Authority (circle one): Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Other "A Information ion end Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity,'employing employees: However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house" '+ or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials ' Please be sure that the affidavit is complete and printed legibly. The Department haUrovide'd a space at the bottom )f the affidavit for you to fill out in the event the Oftice of Investigations has to contact you regarding the applicant. °lease be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant hat must submit multiple pennithicense applications in any given year, need only submit one affidavit indicating current )olicy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or own)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the Ipplicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each ,ear. '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. he Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, Tease do not hesitate to give us a call. he Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents office, of Investigations 600 Washington Street Boston, MA 02111 Tei. # 617-727-4900 est 406 or 1.877-MASSAFE %OMMONINEALTH OF MASSACHUSETTS , • ..,law• jLICENSEp AS A MASTER PLUMBER 1S$UESXHE ABOVE,LICENSE 70 DAVID ;H Byy'ABINE 30SIRCH'MEADOW RD ME,'RRIM;4C _MA O1860-1825 C 9820 05/01/14 142755 I .. f, f. l I .. io-111111�1--�lr �v Date........ ... . ... ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING P©�I 0 /Z This certifies that ................... ......... .. .... .......................... ; ........ has permission to perform .. .... ...... wiring in the building of at ............................................... . ... .. . ........ NorthhAndover, Mass. ... -iN FeZ7 ....... Lic. No. ...... . . . ... .. ......... ...... ELECTRICAL INSPE �R Check It I OM C'om wnwaa& of Ma.46"Letb Official Use Only c� Permit No. 1JepartmanE o`�ina �aroicad Occupancy and Fee Checked _ BOARD OF FIRE .PREVENTION.REGULATIONS [Rev. 1107] (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: City or Town of: ©sit 4 hfo0-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. Location (Street & Number) 77 /'«k POIJ-1 roJ Owner. or Tenant D r f L,.ei.1 Telephone No. Owner's Address roa �+ Dd Is this permit in conjunction with a building permit? 'Yes No ❑ (Check Appropriate Box) Purpose of Building�4 •� 1d Utility Authorization No. EzistlnkService Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead F-1Undgrd ❑ No of Meters Number of Feeders and Ampacity ! Location and Nature of Proposed Electrical Work: &A - G G t (,mmnlvtinn of tho folinwinc, tnhl6 mm; ha wnivod by thv tnrnectnr of Jf i.roc No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans o. ot Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ n- ❑ grnd. nd. o. o Emergency Lighting Batte Units /1 No. of Receptacle Outlets. U No. of Oil Burners FIRE ALARMS I No. of Zones ' No. of Switches No. of Gas Burners o. o Detection nd Initiating Devices No. of Ranges f Total No. of Air Cond. Tons No. of Alerting Devices Heat Pump Tons.__._.. KW._....._, o. of Self -Contained No. of Waste Dis osers Totals: .Number Detection/Alerting Devices No. -of Dishwashers Space/Area Heating KW Municipal Local [I:Connection .❑ Other i,io. o crHeating Appliances Kw Security Systems:* No. of Devices or Equivalent No. of Waterof KW No.'of J Data Wiring: i Heaters Signs Ballasts No. of Devices or E uivalent No. Hydromassage Bafbtubs No. of Motors Total HP Telecommunicationsirma: No. of Devices or E uivalent OTHER: Attach additional detail J 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. INSi ANC'F 'MRAGE: 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 rce, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND .❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: �ovp{1ri� Signature LIC. NO.: €�157V_ (lf applicable, enter "exempt" in the license number line. Bus. Tel. No.: ,7e %d3 �s9/ Address: /�9 I'���-�/'f ag S$l��S �v✓Alt. Tel. No.: . *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,. I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. The Commonwealth of Massachusetts Department of Indusftial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia 9-7 Z' Workers' Compensation Insurance Affidavit:.Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/organization/Individual): Address: /V Ci ; %State/Zip: S /; L vr'l �14 019-W Phone #: Are you an employer? Check the appropriate. box: �Vv 11 Type of project (required): 1..❑ I am a employer with 4. ❑ I am a general contractor and I have hired the sub -contractors . 6. ❑New co on e 1 ees (full and/or :part -time). * listed on the attached .sheet. 7. emodeling 2. am a sole proprietor or partner - ship and have no employees These sub -contractors have g, ❑ Demolition working for me in any capacity. and have workers' employees9. ❑Building addition o workers' -comp' insurance 5. comp: insurance,$ ❑ We are a corporation and its 10. El Electrical repairs or additions required] 3. E I am -a homeowner doing all work officers have exercised their 11. E] Plumbing repairs or additions myself [No workers' comp, right of exemption per MGL c. 152, § 1(4), and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 13:0 Other coma. insurance -required.] - *Any applicant that checks box #1 must also fill out tha section below showing their workers' c=ompensation policy information. t Homeowners who subrriit this effiduvit•indicating-dray aredoing-all work and -then hire.. outside contractors must submit anew affidavit naicating such. tContractors4hat checklhis box=ust attached an additional sheet showing the name of the sub -contractors and state whether or not those cntities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I ane an employer that is providing workers' Compensationinsurance for my employees. Below is the pocky and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration City/State/Zip: ' Job Site Address: � 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 it 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 fib, ce1#fJ,wtdrr4w „andpenaNes of perjury that the information provided above is true and correct In Ojjicial use only. Do not write in this area, to be - completed by -city or town of`ictaL City or Town: ! PermitlLicense # 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 #: Date.... `T! .'."�,(J��f .. ' _66 TOWN 'OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... i� ........ .................................. . has permission to perform ....... AP/M .... ..... ........................ wiring in the building; of../, V I, ... at ... ...... ... ........... . North Andover, Mass. Fee..Jr '�'v c. ................... �iz%1-7,)Zlzv�c INSPECTOR _Chick il 5765 1lYC t,VLYlLY1VLY 1 rr v s .� lI yr �r Ln tu.u.i --••-, DEPARTIIIVPOFPUBIIC Permit No. Jt�L 5 D0ARD0FFIREPREVFVT70N ONSR7C Me120 �- T / Occupancy & Fees Checked APPLICATIONFOR PERE PERFORMELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH T MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATIdN) Dat S S' Town of North Andover I To the Inspector of Wires: The undersigned applies for a permit to perform the electal ' ork desc 'bed below. Location (Street & Number) �� ��(/ Owner or Tenant Owner's Address % G d L-1 A-&,14 I— v I-V U /c f-, Mpl Is this permit in conjunction with a building permit: Yes No (Check Appropriate Boa) Purpose of Building 6/CUtility Authorization No. Existing Service AmpsVolts Overhead Underground No. of Meters New Service Amps Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work W177 ,7-_/7, —7777 _ 7y 77 L-717-1 A/G le, No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above 1:1and Below Generators KVA / round No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pum s . Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Municipal Other No. of Dryers Heating Devices KWLocal Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP 4 OTHER �>Smra QnUage. PlaspantlDdr gtmanatcotMassd BftGataalLaws ItmeaamatLdAiyba==i)Gcyirr>ftC Vie a•Asakdw aleprdiat YES NO Itrav &hniWdva6dpoefofsmrlode0lfe YES IfyouhawdrdedYES,plemittdicalt;thetypeofwrnmWby �1 BOND OTI�x 0 (Ple�espet;fy> ErgimdwDaie E9kn*d Vakre ofEbcftcal Wadc $ Wodc9DStatt 1 hWectimDeteRec}resbd Ro* /r D .5 Firral VFIRMNAME �_r, C /G LraatseNa /0/,i Laati9ee B C,e�.f//�l/ S' Lioa>seNo /� /0/ 3/ Bu*=Te1Na 97:' 3 '0 s'a 33lC v� (/C^ �/ 'V AItTeINa 979 6�S — J? 55</ OWWS WAIVER;IamawaredriftLioarsedoesnothmdreirmrarmca%wiForit a tsimlialegivalatasr gmedbyNbssadumGnrALam anddratmysignabmcnthisperi[app)rmmwanesdbtequ mem (Please check one) Owner a Agent Telephone No. PERMIT FEE $ signature of Owner Of Agent . . �•t 4 Sfn s. t • - \ l w. S .rvuuuviIrr=oILE# VI nuseus umcial Useuniy IV Department of Fire Services Permit No. �� 7 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 (MEC), 527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL WFORW TIOA9 Date: City or Town of: NORTH ANDOVER To the Insp ctor Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 774�o Owner or Tenant eGT250,T we;It'7/���C� Telephone No. P y 2X!2Owner's Address —5114101-- Is this permit in conjunction with a building permit? Yes 9 ---'-No ❑ (Check Appropriate Bog) Purpose of Building i=s- /,,c � Utility Authorization No. Existing Service Amps 12-0 / Volts Overhead ❑ Undgrd of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Amp acity Location and Nature of Proposed Electrical Work: r'.. ..1,. _r.z_ r_n__. �•� No. of Recessed Luminaires "At;iullumnK No. of Ceil.-Susp. (Paddle) Fans mole may be waived b the inspector o Wires. o. of /—> otal. / Transformers % I(VA No. of Luminaire Outlets No. of Hot Tubs a ' Ge erat rs -All No. of Luminaires Swimming Pool Abov�OTl-In_ / O o. r ig g nd:.- { rrid Units No. of Receptacle Outlets No. of Oil Burners 1 FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners ,/ / �ti o. of Detection andInitiatine Devices No. of Ranges No. of Air C d. oust No. of Alerting Devices No. of Waste Disposers Heat u - Number ons KW TO s• .. -E.. ""v.""' ••-••-....••• o. o e - ontained No. of Dishwashers • Space/t 'Heating, KW - Detection/Aler(in Devices Local ❑ unicipa No. of Dryers _ atinglid IA ` ` es' KW Connection Security Suri Systems: of No. of atero. Heaters ��r of �J Ballasts. o. Si 1 Devices or Equivalent Data Wiring: No. Hydromassage Bathtubs s No. of Devices or Equivalent No!io Motors Total HP elecommunications Wiring: OTHER: f No. of Devices or Equivalent r/ Ariacn additional detail if desired, or as required by the Inspector of Wires. Estimated Value of El ctrical Work: ,z '�, �-- (When required by municipal policy.) Work to Start: 611--1? 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�f ice; �d'd'has exhibited proof of same to the permit issuing office. ; CHECK ONE: INSURANCE [j]�ON15 U OTHER [I (Specify:) I certify, under the pains and pdiifalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: .} /7 --- Signature LIC. (If applicabl , enter "exempt" in the license number line.) Bus. Tel. No.-,'? ?It�973 /Sf' Address:' Q'�Ci Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Dep ent 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ Date ��. -. �? ..... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION SACH S ES This certifies that - . . . . . . . . . . has permission for gas installation in the buildings of ....... at .......... North Andover, Mass. Fee :�; . Lic. No: ..�� ... ......... k �. . ........... GAS IN - 6Pf6TOR Check #' 7078 4-1 MASSACHUSE ITIN UNIFORM APPLICATON FOR PERMIT TO DO GAS FTrrING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date jALts la 47 Building Locations '776 C-4454 / o N d /?O"1 Permit # /0;1 Owner's Name Newo Renovation ❑ Replacement ❑ Amount $�_ IPD�E2'f 1✓,onif A-1 Plans Submitted ❑ (Print or type) ZI Name j Address �tp '454eAd V el av&,,'-4 1"A Name of Licensed Plumber or Gas Fitter]All 0 Check one: Certificate Installing Company ElCorp. ❑ Partner. CgFirm/Co. INSURANCE COVERAGE Check onV. I have a current liability Insurance policy or it's substantial equivalent. YesLAQJ No ❑ If h ve checked es lease indicate the type coverage by checking the appropriate box. 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 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 details and mlormation 1 nave sumnittea (or enterea) in aDove appncauon are true anu accurate to me best of my knowledge and that all plumbing work and installatiorls42erformed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts tate od`pnd Wier 14 l -Laws. Title City/Town APPROVED (OFFICE USE ONLY) Sign u of Licensed r1umber Or Gas Fitter L9QjPlumber ❑ Gas FittericeL� nse Nu`mber ®' Master ❑ Journeyman �j x � � z x W W N O O O F x x z Z O E+ W v� F 0O F coo PO, O C4 W Q W W z W F U z r OO � E-4 F W z > -It WW O.�+ En z It O a W O x O SUB-BASEM ENT BASEMENT 1ST. FLOOR 2ND. FL004f 3 R D. F L O O R 4TH. FLOOR 5 T H F L O O R 6 T H F L O O R 7 T H. F L O O R STH. FLOOR (Print or type) ZI Name j Address �tp '454eAd V el av&,,'-4 1"A Name of Licensed Plumber or Gas Fitter]All 0 Check one: Certificate Installing Company ElCorp. ❑ Partner. CgFirm/Co. INSURANCE COVERAGE Check onV. I have a current liability Insurance policy or it's substantial equivalent. YesLAQJ No ❑ If h ve checked es lease indicate the type coverage by checking the appropriate box. 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 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 details and mlormation 1 nave sumnittea (or enterea) in aDove appncauon are true anu accurate to me best of my knowledge and that all plumbing work and installatiorls42erformed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts tate od`pnd Wier 14 l -Laws. Title City/Town APPROVED (OFFICE USE ONLY) Sign u of Licensed r1umber Or Gas Fitter L9QjPlumber ❑ Gas FittericeL� nse Nu`mber ®' Master ❑ Journeyman �j Date... �-..28-. v..t..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................. ......... .... ...................... has permission to perform .............St`n G-..... S',r<%.• %�i................. wiring in the building of �o/� f/r�/.................................... < Fee t..�—. Lic. �L. Check # 2 7837 .................. . North Andover, Mass. ELECTRICAL INS Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. —772—) Occupancy and Fee Checked [Rev. 1/071 (leave hlanlrl 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 WINK OR TYPE ALL WFORMATION) Date: -2 City or Town of. NORTH ANDOVER To the Insp ctor Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) POA f0 2�. Owner or Tenant �(�/� � ������ Telephone No. of 72'2 Owner's Address S/¢jf/fE Is this permit in conjunction with a building permit? Yes �No ❑ (Check Appropriate Bog) Purpose of Building��/�/ A�®w Utility Authorization No. Existing Service �W Amps % O / Volts Overhead ❑ Undgrd ❑ANO. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No, of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans ranee may oe waived by the Inspector of Wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- El o mergency Lighting nd. rnd. Batte Units Battery No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Alerting Devices No. of Ranges No. of Air Cond. TonaTotal No. of Waste Disposers eat ump Number Tons .... _ _ Totals: No. o Self -Contained Detection/Alertin Devices No. of Dishwashers Space/Area HeatingKW Local ❑ Municipal ❑ �� Connection No. of Dryers Heating Appliances KW Security Systems:* No. of WaterNo. of No. of Devices or Equivalent Noof. Heaters KW Data Signs Ballasts No. evices . of 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 Val4ofElltrical Work:(When required by municipal policy.) Work to Start:(6 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCEGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance includmi "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage isin f has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ OTHER ❑ (Specify:) I certify, under the pains and p aloes ofperjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: -//��C1C l �T�Z�f7 Signature s LIC. NO.:C;7- (If applicable, enter "exempt" in the license number line) Address: Bus. Tel No.: 12& 973�/`S-9% �^ Zle c G?`�� Alt. Tel. No.: *Per M.G.' c. 147, s. 57-61, security work requires Dep ent 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 agent: Owner/Agent Signature Telephone No. PERMIT FEE. $ C ,. l "`� .y. � . t. f L s• � The Common wealth of Massachusetts nit k� ! Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 {' z www n:ass.gov/dia . Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeQibiy Name (Business/Oraanization/individuall: Address:_ 42-- City/State/Zip:_ �l�e'��� Phone #:. 97f- 9%3 %fes Are you an employer? Cheek.the appropriate box: 1. ❑ 1- am a employer with 4. ❑ I am a general contractor and I es (full and/or part-time).* have hired the sub -contractors 2. 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.] 3.0 I kin a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No -workers' comp. c. 1.52, § I (4),'and we have no insurance required.].t employees. [No workers' comp. insurance required_] ` *Any applicant that checks )tfl I most also fiat out th ti bei h Type of project (required):6. [] New construction 7. ElRemodeling 8. Q Demoiition 9. ❑ Building addition 10.0 -Electrical repairs or additions 11.0 Plumbing repairs or additions 12.[] Roof repairs 1.3:Q Other e sec on ow s owing their workers compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hin outside connours must submit a new affidavit indicating such. ;Contractors that check this box mustattsched an additional sheetshowing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is.provtdingworkerscompensation insurance for my enployee.L Below is the information. policy and job site Insurance Company Name: ' Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'. compensation policy declaration page (showing the policy number and expiration date Failure to secure coverage as. required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ry fine up to $4500.00 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 OfPerjurY that the information provided above is true and eorreeL Signature: Date: Phone #: Eal" only. Do not write in this area, to be completed by city or town official n: Permit/Lieensehority (circle one):Health 2. Building. Department 3. City/Town Clerk 4. Eiectrical Inspector S. Plumbing Inspector son: Phone #: Information and Instructions ` Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the'foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. 'However the owner•of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on'the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation. affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es),and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with,,no employees other than the members or partners, are not required.to carry workers' compensation insurance. if an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, notthe 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 companies should enter their self=insurance license number on the' appropriate dine. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided 'a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permittlicense 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 flog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investipti.ons 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. # 617-7274900 ext 406 or 1-977-MASSAFE Fax # 617-727-7744 Revised 5-26-05 www.mass.gov/dia 4177 Date ./'::�) -S/ - "-, --> ................................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... ................. .......... ................................... has permission to perform wiring in the building of at ....... .4 Fee ............ Lic. No .............. Check ....................................... n.; North Andover, Mass. .................................................. �—ELEcrmcAL INSPECTOR THECOMMONWF,ALTHOFMASSACHUSEM Office Use only DFM41?771 l'0FPUB,UCSAFEIY �� 77 BOARDOFFIREPREVJuwoNRF.('UTA770NS527C11BZI2 01D Permit No. �^ Occupancy & Fees Checked APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date .Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work describe elow. Location (Street & Number) Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes No �— (Check Appropriate Box Purpose of Building r tility Authorization-No— Existing Service Amps�Volts Overhead Mi Underground g No. of Meters New Service Amps / Volts Overhead � Under 'ound � —� ---� No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total No. of Lighting Fixtures Swimming Pool Above Below KVA Generators KVA round round No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch outlets No. of Gas Burners No. of Ranges No. of Air Cond. Total FIRE ALARMS No. of Zones Tons No. of D:' oosals i�u. f Heat 1 otal 'Total LDe ion and i' Pum s Tons vices ---�� No. of Dishwashers tN ace Area Heating KW ing Devices ntained unding Devices No. of Dryers ting Devices gerMunicipal O�er"�� No. of Water Heaters I{W Connections a of EBailasis o. of ns No. Hydro Massage Tubs of Motors Total HP k OTHER: imuarloeCo�age PtnAiaz�mdleteg�rtarnays�(��enaallaws haveaam tlia)11tyk1Sut&=Pbky>ri kxbTCorr P] GDWWOVISwb legtuvalelg YES NO haveWbnrftdvabdproofOfMWOthe Oliic, YES ff �� bo�Igthe box LLL���JJJ �' YES pkm xbc&thetypeofa NerdWby VSURANCE BOND M OIFER �-7D& i�olkto Start i r s �-C x Date" Rcugb t�11_►1C ? � ` Estitr>ated Vahle ofDe�l Woiic $ ignadu xla-Tieanaltiescfperjtuy, ttFinal RMNAME f OZ M t6 ' (�\- r L'cuwNio. Signahue v I.ioaseNo BusnnessTel.No. i�'NII2'S IIVSURANCE W Alt Tel No. A1VER;Iamaw&ethatthelico�edoesnothavetheitLanancecovelageorgSmbs urialegmva)mtasmgttirodbyMa%whuseMGetlE�dlaws 9 that mysignahneonthis pan itapplication waiwstis wquitt� lease check one) Owner a Agent Telephone No. PERMIT FEE igna re o caner or gen . >` D SCP 095 BRANCH XA 2 9 1 I I M012043917-001-00001 I ANNUAL. MARYLAND CASUALTY COMPANY PRECISION PORTFOLIO POLICY COMMON DECLARATIONS PRECISION SPECIALTY CONTRACTORS TRADE CONTRACTORS PROGRAM This policy consists of the declarations as well as the coverage forms and endorsements li-,tt-d on the Forms and Endorsements Applicable List. SHAWN COWHIG ELECTRIC ONE HILLS ROAD MIDDLETON MA 01949 »>; BRANCH NAME AND ADDRESS ZURICH GROUP -AUBURN 15 MIDSTATE DRIVE AUBURN MA 01501 (508) 721-9101 BUSINESS ENTITY: INDIVIDUAL POLICY PREMIUMS In return for the payment of -the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as. stated in this policy. This policy consists of the following coverage parts. This premium may be subject to adjustment. PREMIUM COMMERCIAL GENERAL LIABILITY COVERAGE PART $ 590.00 TOTAL ANNUAL PREMIUM Countersigned by ICOMMON 760006 Ed. 3-00 $ 590.00 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Copyright, Insurance Services Office, Inc., 1984. Copyright, Maryland Casualty Company, 1993. INSURED'S COPY Date 06/05/2002 Date. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING N4� I // This certifies that . . I . -. - . ��q_ /L ........... ...... has pe' rmission to perform f 1.✓C!.C:..!� plumbing in ..L. ZV at. ...... North Andover, Mass. Fee,3/)..??) Lic. No..1-31M . ............. ................ PLUMBING INSPECTOR Check # 6343 MASSACHUSETTS UNIFORM APPLICATION FOR PyW ERMR TO DO PLUMBING r ��f Mass. Date c / J / - _ Permit07 Building Location 7 76G�c� i- rc���'�1 oz.s Name k -W L,6, �7 TYOf Occupancy'" -3. �' — New O Renovation D Replacement 01-� Plans Submitted: Yes Q No G FIXTURES Installing Company Nameof UCefWW Plumber Check o O Corporation O Parte P'urnlCm 90MUNCE 9XWERAM 1 have a current Iiat ility pormy or its subsUntial mWivalent which meets the requirernertts of MGL Ch. 14L If >� Yes CheckW No A Y. O Please indicate the tppe coverage by chedmV the appropriate box. A liability insurance policy Otter tYPe of nt *mnitp O Bond G OWNER'S DIUMNCE WAtVM l.am aware that the licensee does not have the by ChaPler 142 Ot the Mass. General Laws, and that my signahaeonthisPerinit application wed requirement. Cheek one 5gwe of Owner or Owner's Age Owner Agent G 1 heretri► cerwy shat all of the details and ifdom atien I hare subrnined the rust of my knowledge.and that all Pkm*ing work and entered) �O"e 'on are true and acu me to. Dr ire o = wit aN per irw4 provisions of vo.liAa-- — t>e ormed under the pennif issued toroft appgplion w81 State PW aft and 942 of the Genera! laws. 150p,*Fm of i umnse Wnhbw / ?in/e Y Y • • = = .. ■EMEMEMNEUMMEN ■EMEMEME NOME 0sm®mmmmmm■ MEMMENEMSE■ .. ■EMEMEME mmm,e MENEENE■ Installing Company Nameof UCefWW Plumber Check o O Corporation O Parte P'urnlCm 90MUNCE 9XWERAM 1 have a current Iiat ility pormy or its subsUntial mWivalent which meets the requirernertts of MGL Ch. 14L If >� Yes CheckW No A Y. O Please indicate the tppe coverage by chedmV the appropriate box. A liability insurance policy Otter tYPe of nt *mnitp O Bond G OWNER'S DIUMNCE WAtVM l.am aware that the licensee does not have the by ChaPler 142 Ot the Mass. General Laws, and that my signahaeonthisPerinit application wed requirement. Cheek one 5gwe of Owner or Owner's Age Owner Agent G 1 heretri► cerwy shat all of the details and ifdom atien I hare subrnined the rust of my knowledge.and that all Pkm*ing work and entered) �O"e 'on are true and acu me to. Dr ire o = wit aN per irw4 provisions of vo.liAa-- — t>e ormed under the pennif issued toroft appgplion w81 State PW aft and 942 of the Genera! laws. 150p,*Fm of i umnse Wnhbw / ?in/e f FJ w 9 Z O A f r p. e Ia . 2 p p Z Z p p A A r A O O a � 2 w 9 Z . O p. Ia . p p Z p A r A O 2 p q . AI A S A p w A A � 1 ' r A f p O Z � � O O� � 3. O C O A 49 2 C e' Z D' 7 y 9 O . O p. Ia . p p A r Date A es. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies .......................... has permission to perform plumbing in the buq*dings of...... ................... ,North Andover, Mass. F&,: -?o )-�. ..... Lic. No"OG ... ........ P PLU INSPECTOR .. .............. LU Check # 5751 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) Mass. Date �' Permit # - AW I & Building 6 Locajtio[nQ�i�G r-, / One wrs Name U l b�O — OZO ! Type of Occupancy l New D Renovation 0 Replac ement m✓ Pians Submitted: Yes O No C FIXTURES Installing Company Name Ari o; e,; c ® Corporation Address 5yy - w%.n,no ® Partnership 1=/r Vr Business Telephone '1 - Name of Licensed Plumber BOURANCE COVERAGE: 1 have a current liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142- Yes ) h No 0 If you have checked yes, Please indicate the type coverage by checking the appropriate boa. A liability insurance policy -g Other type of indemnity p Bond C OWNER'S INSURANCE WAlvm 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 pa rro application waives this reouireernenL Check one: Signature of Owner or Owners Agent Owner ::: Agent G •••• ..�..o..� o.w...uv.s.w.os. 111 'll" Mr 0"" m above apomm we true and a=umw to tree best of OW lQfowied all ant that all vWim mg wait and installations under the Pem�it issued forttus application will be inoareplianoe with all Pertinent prorisiores of the plu 19 ant C Otet 142 of the General Laws. Signathue of Licensed Type of Licenw Master ix- License Number __ 133.101., E mom Installing Company Name Ari o; e,; c ® Corporation Address 5yy - w%.n,no ® Partnership 1=/r Vr Business Telephone '1 - Name of Licensed Plumber BOURANCE COVERAGE: 1 have a current liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142- Yes ) h No 0 If you have checked yes, Please indicate the type coverage by checking the appropriate boa. A liability insurance policy -g Other type of indemnity p Bond C OWNER'S INSURANCE WAlvm 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 pa rro application waives this reouireernenL Check one: Signature of Owner or Owners Agent Owner ::: Agent G •••• ..�..o..� o.w...uv.s.w.os. 111 'll" Mr 0"" m above apomm we true and a=umw to tree best of OW lQfowied all ant that all vWim mg wait and installations under the Pem�it issued forttus application will be inoareplianoe with all Pertinent prorisiores of the plu 19 ant C Otet 142 of the General Laws. Signathue of Licensed Type of Licenw Master ix- License Number __ 133.101., C z m 30 s � on O Z 30 V z v 'o s o M v = O 0 C e O e e a > O O > in > z e 7 e A O z e TO -.,.� DATE TIME 13 PM P FRo " ����G I PHONE�� . C-j7� ._ H1 CELL (� / o� O F b Gl( !lt�y FAX ( ) E E 9 e o��� Gar fluyr �U M s 1 �o_-e d b. rr� �14 M E � �1 t /4 I f� G�9 �I v O E-MAILADDRESS SIGNED Y PHONED ❑ BACK ❑ CALL RNED ❑ IWANTS SEE YOU ❑ AGAIN ALL ❑ yyAS IN ❑ URGENT ❑ 4230 4 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....................................................................... has permission to perform ............................................................... I/ wiring in the buildingf ..................... ol ......... at I 7� ..... . North Andover, Mass. ...... a Fee 3. & ...... Lic. N1u? .. z . . ", ........................................ !ELEcTRicAL INSPECTOR Check # TO DATE 22 TIME ! AM PM P #F PHONE H CELL OF FAX ( ) w wO� N � E M E M Sc.- s E A M E O E-MAILADDRESS SIGNE PHONED❑ CALL ❑ RETURNED ❑ WANTS TO ❑ WILL CALL ❑ WAS ❑ URGENT❑ BACK CALL SEE YOU AGAIN TO DATE TIME AM PM FROPl HONE CELL( OF O FAX E s s A EM G E O E-MAILADDRESS Si E PHONEDF] I CALLE:] RETURNED[] WANTS TOO AGAIN WAS 07URGENT[:] BACK❑ CALL SEE YOU AGAIN ,04 ., - .. . � � --,�� i � , �' _ .� 0. _ ^I � 'tJi \ r V' THECOMA GAME 1LTHOFMASS4CHUSEM . Office Use only DEPARTMIATOFPUBLICS4MY Permit No. 412-30 BOARD OFFIREPREVEMONREGUTAHONS527CMR-1200 'y Occupancy & Fees Checked APPLICA71 ONFOR PERMIT TO PERFOIZMELECTRICAL WO ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12`.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Win -c- The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant 11 1 LSD t� 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 M Underground �' No. of Meters New Service Amps�Volts Overhead © Under 'round g No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets (40 No. of Hot Tubs No. of Transformers Total No. of Lighting Fixtures Swimming Pool Above BelowGenerators KVA No. of Receptacle Outlets No. of Oil Burners round round KVA No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners No. of Ranges No. of Air Cond. Total FIRE ALARMS No. of Zones No. of Disposals No. of Heat Tons Total Total No. of Detection and No. of Dishwashers Pumps Space Area Heating Tons KW Initiating Devices KW No. of Sounding Devices 1 No. of Self Contained No. of Dryers 1 Heating Devices Detection/Sounding Devices I KW Municipal LocalNo. '� Other No. of Water Heaters Key of No. of Connections � Si ns Bailasis No. Hydro Massege Tubs No. of Motors Total HP y . OTHER FrmlrW=CoWraW- RnhallotlrmgmmeMdA4a%adn>mC*ncdLaws [havea=entLabiltl Lmampokylwkl algCorrlplctpOpa CC)wWoritswbwftialeqtrivalent YES NO lydcingthe[havembmetivalidploofofsarnetothe0 YES ridh]TYulmedecicedYES,pleasen>�d�egFOfcovt by 3rac3angthe bo L,.j NSURANCEEa BOND OTHER (P Spaa{Y) FnDale VorktoSW11 1?)vValwofHoctacalWo& $ igtadundcr ePt��alhesofpajuty k l pectiDWeReWessedR mgh Final LimmNo. LiamseNo am Tel No. Alt Tel. No. I ••1NL:&',-3uN3Urc--vvUr-writvrx;lamawatethatftLiceawdoesriothavedeuistnanceoDverageoritss<Ilstpu�equivalulas ddlatm si tegttaedbyMassacht>s�lsGenaalLaws y g<�ahneontiuspetmitappfica6iorlwaivesthisleqttit�l�t 'lease check one) Owner M Agent Telephone No. PERMIT FEE $ S� Signature o caner or gen mom Date. - 17- / TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ....................................... has permission to perform ..................... plumbing in the buildings of ................................... at North Andover, Mass. Fee�,26, Lic. No. NF k . ............. P�L0111641G'INSPECTOR Check # 93 (A 61 5374 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) " NORTH ANDOVER, MASSACHUSETTS Date Building Location Owners Name / / Permit # Amount o , Type of Occupancy New Renovation1:1 Replacement Plans Submitted Yes No ❑ (Print or type) p y�/'✓%�YYZI S� Check❑Certificate InstallingCom an Name Corp. Address C" L5 I Partner. Business Te ep one �] , ,^� n� Q ❑ Firm/Co. Name of Licensed Plumber: 8 1,91"11 z Insurance Coverage: Indicate the 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 Owner Agent rj 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 Per ' Usued for this plication will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Codee General Laws. By:Signature oi 1-icensea riumoer OV Title Type of Plumbing Li ' J F-' City/Town icense um er '� Master ® Journeyman APPROVED (OFFICE USE ONLY / • • ' MIN �. Mo (Print or type) p y�/'✓%�YYZI S� Check❑Certificate InstallingCom an Name Corp. Address C" L5 I Partner. Business Te ep one �] , ,^� n� Q ❑ Firm/Co. Name of Licensed Plumber: 8 1,91"11 z Insurance Coverage: Indicate the 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 Owner Agent rj 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 Per ' Usued for this plication will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Codee General Laws. By:Signature oi 1-icensea riumoer OV Title Type of Plumbing Li ' J F-' City/Town icense um er '� Master ® Journeyman APPROVED (OFFICE USE ONLY Date.. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ....................... has permission for gas installation ............ in the buildings of .................................... at North Andover, Mass. Fee.,-�Lic. No.......... .......... ........... -GGASAS I TOR Check 4134 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS I TITING (type or print) / I _ Date ---4E2 ! 1d 6% NORTH ANDOVER, MASSACHUSETTS f Building Locations ` l 6 6�p&-7� /V,_6 12 t�.- Permit # i 3 Amount $ Lt- �� A) T Owner's Name � New Renovation Replacement 0 c Plans Submitted SUB -BASEMENT BASEMENT 1ST. FLOOR LND. FLOOR 3RD. FLOOR {TH. FLOOR TH. FLOOR TH. FLOOR TH. FLOOR I hereby certify ( ent�edl m above applic tion'are true and accurate to the that all ofthe details inion 1 have submitted or best ofmy knowledge and that all plumbing work and installations pel1b, under Permit Issued' for this application be in compliance with all pertinent provisions ofthe Massachusetts State Gas�142 ofthe General Law . le .y/Town "PROVED (OFFICE USE ONLY) Signature ofLicensed Plumber Or Gas Fitter Plumber Z,/ 4 &-" P� 0 Gas Fitter License Nurn5er MMaster ci Journeyman