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HomeMy WebLinkAboutMiscellaneous - 8 SAMUEL WAY 4/30/2018a ra 4 a w This certifies that ... �4 W ...................... I ............. has permission for gas installation �Itj.Al. ............... -r,-��, in the buildings of ...,S...v.................. '�� :50 vIN Q. e& ejx6t at ... ... ] , �ort And ver, ass. Fee. . Lic. NA6.0 ... . M� ......... . ....... GASINSPECTOR . I :?-) Check # 3 8370 1b N MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - CITY _ �_�/ _- MA DATE L_&2 11j PERMIT # JOBSITE ADDRESS._7,O;QpT- OWNER'S NAME GOWNER m_ _ ADDRESS TEL _ _ _ _ FAX [__' j TYYPPIENOT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ® RESIDENTIAL CLEARLY NEW:.. RENOVATION: El REPLACEMENT: D PLANS SUBMITTED: YESF-1 NOrW _ APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 1 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVEI-_ ._�- DIRECT VENT HEATER DRYER FIREPLACE - r- t FRYOLATOR FURNACE GENERATOR ,---- __j __ -( I GRILLE t,_ ._ i...___- (.__-- ---- --- _,__.1 ..-__- __ .. -_-_ r! - -- . INFRARED HEATER - , ` _ ! , _. I .r -- LABORATORY COCKS MAKEUP AIR UNIT=i 1- - 1 I_---( L-= - I ._, _.�. - h,-_-- � _� —. I - -f 1.-- OVEN __. L! :--� _ .IL._-,-<<_- .1_=..T.. I1.----_I__:--� -- -1-L- ._ - - 1 POOL HEATER ROOM / SPACE HEATER _ . __.. i_ (.. . 1 ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER _-(''•.. _.,i _.r I _ 1 t-- -, I - I_ �L { m E 1. _ WATER HEATER OTHER - - INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO D IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY _ OTHER TYPE INDEMNITY BOND �_]f OWNER'S INSURANCE WAIVER: I am aware that the I censee 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 �I 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 c pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME .-- - -?1 LICENSE # ._ ._........_ _ SIGNATURE MP _ MGF 0_1i JP =_! JGF E LPGI CORPORATION # PARTNERSHIP # I LLC - = COMPANY NAME:L� - ADDRESS CITY4_ !- STATEu ZIP (TEL FAX CELL EMAIL 1b N z H U W' a w o rl O y� } w � w a O LLI 4t � I-- w a Cl) W 5 LLI W w N �a a o a a U W IL CL , a N `w z w I-- LL. W H z F� 9 }a . V r The Commonwealth of Massachusetts ,Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AM 02111 , www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name P' (Business/Organization/Individual):—UiT ;, � (� L4466A�, � (j� cag (p n Address City/State/Zip: Phone #: q78 •8/5 Zp to Are ou an employer? Check the appropriate box: 1. am a employer with Z 4. El 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.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions 11. lumbing repairs or additions 12.M 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: GLUES 1N9449C . Policy # or Self -ins. Lic. #: "W C,, fu ?QCo? - Expiration Date:_ ` % 8. 12 " Job Site Address:_ 5,6o0.z City/State/Zip:f9O iA&ft1!<4n, YA. 018Y,57 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 fnie 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 :)f 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 ceV under the pains and penalties of perjury that the information provided above is true and correct. .hone #: 418IS& 2010 Official use only. Do not write in this area, to be completed by city or town official, City or Town: Permit/License # I. Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written" An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and wh`o resides therein;"or ilie 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 eiri ioyment be deemed to be an employer." MGL chapter 152, §25C(6) also states that"every state or'loc"al licensing agency shall withhold the issaance of, 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 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, 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. c®mlete and printed legibly. The Department has provided'a space at the;bottoiri of the affidavit for you to fill out in the event the, Office of Investigations has to contaci you regarding the applicant. Please :1 a su e`,to fill i 4he permit/license number which will be used as a reference: number: ". In addition an applicant' that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, lease do not hesitate to give us a call.. P g The Department's address, telephone and fax number: Y The Commonwealth. of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.govldia I x C? 0-0 -4 in z M - C) 03 m U) 2: cncn rh >m > o z )> Ul m m > > -4 --i C, P I z ch Cf) m (1) 00 . to C:) U) fn M co (J) 6 &4A4XAL Signature x : . \ \ / / ° ' ( �=; :3 U) am ._ «E e ~ }} 0 q � ) 0�OL \a} § e\3o CD = . =E@°m� 00 aae 2 \f0)\\k /ƒ£ \ §j \\\§ )\_CO 2 W 22\E22J E)s;a&/ J };» ƒ/M /�\ \ 1 }) \�\/\D / �') !/. &2—,\C ¥y aCD \(///f 0 \. ]. $0255® e8 . coa / �`@aac ' 0® \ \\//\/ 0 -co ^ a / / WEA IMAGES VIDEOS MAPS MORE bing F G p Sign it - Z. of 5 Thnrsrla\r Ort 11 9n19 oo•Fo enn 0 oic u ne This certifies that ....... P!C, •c�T/Z� has permission to perform.. ..?� wiring in the building of .... /Yj./.`h , , . , , , , , , , , , • ........ . at ... .. Sy (.r . , .t.C/ , , , Noah Andover, Mass. Fee .L1 "a--� Lic. No. a ......... �,� ' ELECTRICAL INSPECTOR t Check #7 11144 :0 Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked 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 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) City or Town of. NORTH ANDOVER By this application the undersign gins notice ohhissor her int. Location (Street & Owner or Tenant Owner's Address Date: _ To the Inspector of Wires: to perform the electrical work described below. Telephone No. Is this permit in conjunction it a bu1ilding permit? Yes LJ No LJ (Check Appropriate Box) Purpose of Building (� 4 /� Ji Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Meters No. of Meters 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 W BOND ❑ OTHER ❑ (Specify:) I certify, u91, t/ ain ndpenalties !fperjury, that the information on this application is true and complete.lm FIRM NA. Y �. LIC. NO.:d:J I Licensee: Signature LIC. NO.: a3�3w (If applicable e exempt" in th license number line) ,1 Bus. Tel. No.: Q j Address: phi C illi 1 V �U OY� N•J1 o 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. J � .-. • �Ji.�Ji:lYl.l..111.L'V�{.{GJ-:-TJ(�C-�•(TTT����J•��--���.Lt■Jay'R.+..�.�1■�®yp'7(�P`�p{����yTp/�pp�� .r-+.S��J.:��UJi.*.�.R.1 .a.a++JL ®J�.'eAo • — JJ�LIL.v.i�.L •i"/Vr'. VrtO.� ' • r • .. I ,• � . 32�ssec�-^� � �'aiietr•�� �' �e-xnspeeizox�x•et�uzXed'($�OAQ)•-� � �uspectoxs' �opzme�afs: - {�'nspee#axsyuzgaaiu�Ce��tofniiiaTs} � _ date . MAL )WSPACJmOW; Yn�iecfo�-s omm.enfs; ' ( ns iectoxs', zgnafuzeZT ..).o Wfials) Pate ?assed--[ j �+`ailec�'-l) ate-xnspeetzo�xec�uixet����0.00)�[ � ius ectozs° Comments. (lnspectoxs' fgizafuxe��o �niffa7s) Date ssec,— I) raved—[ j Re-fnspeed6n required ($50.0) - [ � ,,pecfoxs' eomm.eptfs: Zuspeetoxs',�zgn�iuzeK�onzf�a7s} Date ,e r� -- E � �`azter� �-• ( )_ ' �e �nsp ecizon requixer� ($50.00) •- [) I eetozs' colhMents: MIS ectox�' zgnatrzre no xnif ads} • cafe The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): q Address:_ i G jA OFI Yk City/State/Zip: NJJDY) ,R 03��l Phone #: UMUJ20d Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I ployees (full and/or part-time).* have hired the sub -contractors 2.m a sole proprietor or partner- eI listed on the attached sheet. # Ct 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 10Electrical repairs or additions 11. El 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: '<licy # or Self -ins. Lic. #: Jnr Site Address: Expiration Date: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereftxj�rtj& under t/aepps andpenalties ofperjury that the information provided above is true and correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' 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, 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 submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE I RPv;gPrl 5_96_05 Fax # 617-727-7749 Da e ........ ? ....... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ............. This certifies that ........ . has permission for gas installation ,C--,/........... in the buildingslof . ............ I ........... at PF: ................. North Andover, Mass. Fee/ 010 L.ic. Q, LL-. e. .. ........... C/IGKS-INSRWCe0R Check # L/S F 6757 .C\- MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING C't/Town• ty �^ Y -v C� C "I Date: Q Permit# Building Locatlon:Q-4'e4'c (V m . Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New:4 Alteration: ❑ Renovation: ❑ Replacement ❑ Plans Submitted: Yes ❑ No ❑ � � w 0 9 c c m a M I v yo. z v, °o M w O Z Z p ac w O F o W W W W Z q ee 40 W M WulWj 1- O Z J WmZO 5 aG O O a O Z W V G U. O S Z IL l: P>>> a O Installing -Company Nam�tSL11;�_` Addressc�C JacCrrrarr r N. �•�.�� T` U Firnvvcompany Of LicensedPlumbeNG F 1m�#> i►Xs i. 4%. INSURANCE COVERAGE: 1 have a current Nabi ty insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 Yes E3 No ❑ 0 you have checked Yes. please Indicate the type of coverage by checking the appropriate box below A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAfVER: l 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 Signature of Owner or Owner's Agent Owner 11 Agent ❑ By checking this box ; I hereby cerWy that all of the dem and information I have submitted (or en1*nKQ regart" this application are true and accurate to the best of my Knowledge and that aft Wwfth g work anal histallatiora performed under the permit issued for this application will be in compliance with all Pertinent provision of the Alassachuseds State Plumbing Code and Chapter 142 of the General Laws. Type of Licence: BY ❑ Plumber Title El Gas Rthn S" naturePllum Gas Fitter tCity/Town0'1ournsyman License Number: I{ '` 7 APPROVED OFFICE USE 0011 0 LP Installer Date.... ... .. ... ... ....... O's.an e 'H TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .............................. LL� Gly �2J AG�/2/� ............................................................. has permission to perform .................. wiringinthe building of .....................� � ............................... U 5 , North Andover, Mass. r Fee..................... Lic. No.............. ..................� ......................... LE TRICAL INSPECTOR G Check # ✓ 8.658 �-� Commonwealth of Massachusetts Official Use Only Department of Fire Services FmiNo. 2F6�BOARD OF FIRE PREVENTION REGULATIONS cupancy and Fee Checked Rev- 1/071 nPavP M —L -N 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 INFORMATION Date: -3 - 2-s__`7 City or Town of: NORTH ANDOVER By this application the undersigned To the Inspector of Wires: gn gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) ]�r� Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? yes Purpose of Buildin l N° ❑ (Check Appropriate Boz) g— -ps -, 4.7 �/A / Utility Authorization No. Ezisting 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: 14 Completion of the followin table nup, be waived by the Ins ector of Wires. pNo.of Recessed Luminaires No. of Ceil.-Sus a• .o Total p. (Paddle) Fans Transformers KVA Luminaire Outlets No. of Hot Tubs Generators KVA Luminaires Swimming Pool Above In- o. o in envy d. ❑ . nd. ❑ Battery Units — No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS N o. 0 --Zones No. of Switches No. of Gas Burners No. of etection and No. of Ranges No. of Air Cond. Total InitiatinLyDevices Tons No, of Alerting Devices No. of Waste Disposers eat PSP umber Tons _ No. of Self- ontained Detection/Ale or Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal Connection E] other No. of Dryers Heating Appliances KW Security Systems: No. of Water o of No. of Devices or E uivalent Heaters KW No. of Data Wiring: Signs Ballasts . No. of Devices or E nivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivale it OTHER: S'PG yr i /�-14 /r7 Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. ! /Od � � Work to Stark 3-zS`— ,� I f (when required by municipal policy.) / 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 and complete - FIRM NAME: Vl Licensee: LIC. NO.: W.SSG �v� Signature (If applicable, enter "ezemt " inthe1icnumber line.) LIC. Address: 2 %Gf r// �� tom% M // Bus. Tel. No.67,J -b,f-,? -V )! *Per M.G.L c. 147, s. 57-61, security work requires D 7 Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee doles not ehave the 1liabili Lic. No. required by law. B m signature y q h' insurance coverage normally BY y gnature below, I hereby waive this requirement I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ Aal�x 69zc N aaw-ll AZI-714��v �"A N r7 The Comi'nonwealth of Massachusens j ! Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 c ; www. news gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Applicant Information /� Please Print Legibly N8II]e (Business/organiration/individual): 5J 111 V� /7`n TPnJ'V4 e lylel t.,4 Cityl.State/Zip: LK64-2 .r /�a/S- �/ Phone #: - 9P 7J- to o? -6 Y7" Are you an employer? Cheek -the appropriate box: I. f l aro a employer with % 4. ❑ I am a general contractor and I employees (fuil and/or part-time).* 2. [] I am -a sole proprietor or have hired the sub -contractors listed = pwtner- on the attached sheet ship and have no employees These suii-contractors have working for me .in any capacity, [No workers' comp, insurance workers' comp. insurance. 5. ❑ Weare a corporation and its required.] 3. ❑ 1 am a homeowner doing officers haveexercised their all work right of exemption per MGL myself. [No -work='' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required_] Type of project (required): 6. 2few construction 7. ❑ Remodeling $. Q Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other fi--"- - ..�� wso nu our me section below showing their workers' compensation policy infomuition. 1 omeownets who submit this affidavit indicating they am doing all work and then hip: outside contractors must submit a new afFidavit indic ;Cotttractnrs that check this box mustattactted an additional sheet showing Creme the of the sub-ccmnactvrs and their wor,' r:� . paating such • i rf„-rarstior�. / am an employer that is providing workers' compensation insurance or e informatiom ftployem Below is the policy and job site Insurance Company Name: G Ya n gak Policy # or Self -ins. Lic. #: W6- Z S'ej ,s�j Expiration Date: -- Job Site Address: .SQirrt t til/ City/State/Zip: Ai • •'�4/d�(�l�F.v /� Attach a copy ofthe workers' compensation po ' y declaration page (showing theii po cy number and expiration date} Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal fine up to $1,500.00 and/or one -yew imprisonment, penalties et►a n of i Y prisonment, 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. 1 do hereby certify under the p and patties of perjury that the information provided above is true and soured i �r FTPJ;C==e Phone #: 9 7 �- G �Z (e Y 7 y only. Do not write in this area, to be completed by city or town ofciat City or Town: Permit/License # Issuing Authority (circie one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Date... ... ....... . ........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING .......... This certifies that-k.—".z .... ............ . ..... has permission to perform ......... /� .........................................P......... wiring in the building of ..... ............................................. . ............... North Andover, Mass. at.. :t��Ltd ........................... FeeZ�� ......... Lic. No'�� .............. �c Mu Check # 8606 y. R Commonwealth of Massachusetts Official Use Only Permit No. g�0 Department of Fire Services Occupancy and Fee Checked Z— BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/051 (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CodeMEC) 527 CMR 12.00 (PLE)10q ASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: A1�ArH POOV�12 To the Ins ecto of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 10' 42j f;a M 0 k__ 1 ate► AY Owner or Tenant 5;; 6 1Q00iD Telephone No. Owner's Address a0 Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 'Z�J EU,1 ll.) & Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service l,� Amps i L) / J Volts Overhead ❑ Undgrd No. of Meters Number of Feeders and Ampacity \ v Zoo n m ie - Location and Nature of Proposed Electrical Work: rA M I L'i�ipa JJ G r,, i a �,ti { 11 wino tnhla may ha waived by the InsDector of Wires. Roach uumhurtut ueiuu tj ucau cu, w — . ..y .• � ---- Estimated Value of;Electrical Work: (When required by municipal policy.) Work to Start:A 17 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C RAGE. 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 andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: Interstate Electrical Servi , s rpor-at i, LIC.N .:A-5217 Licensee- Pasquale A. Alibrandi Signature I (Ifapplicab�r_nt 'e,eej"inCoves number u berlin.� Billerica MA 01862 Bus.Tel.No.:978-667-5200 Address: Alt. Tel. No.: *Security System Contractor License required for this work; if applicable, enter the license number here: 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: S Signature Telephone No. --- -- -1 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. ❑ rnd. ❑ o. o mergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones Detection and No: of Switches No. of Gas Burners itiatin Devices No. of Ranges No. of Air Cond. Total Tons Alerting Devices pLocal Heat Pump Number Tons KW Self -Contained r0 No. of Waste Disposers , Totals: Detection/Alerting Devices No. of Dishwashers / Space/Area Heating KW Municipal ❑ Connection ❑Other Heating Appliances KW Security Systems:* Equivalent No. of Dryers No. of Devices or No. of Water, No. of No. of Data Wiring: Heaters Suns Ballasts No. of Devices or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs JNo. of Motors Total HP No. of Devices or Equivalent OTHER: 1.,�.,?- f'Wirps .,.d J. tA. CCIO Roach uumhurtut ueiuu tj ucau cu, w — . ..y .• � ---- Estimated Value of;Electrical Work: (When required by municipal policy.) Work to Start:A 17 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C RAGE. 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 andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: Interstate Electrical Servi , s rpor-at i, LIC.N .:A-5217 Licensee- Pasquale A. Alibrandi Signature I (Ifapplicab�r_nt 'e,eej"inCoves number u berlin.� Billerica MA 01862 Bus.Tel.No.:978-667-5200 Address: Alt. Tel. No.: *Security System Contractor License required for this work; if applicable, enter the license number here: 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: S Signature Telephone No. 4l% -, a-- 0632- & -/3--o r //I pORTH O F Date6; TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING oe­ ,SSACHusi _ . /�_ This certifies that '.� . ,./.. j.....:.... ..... . has permission to perform ... 77: .. ... . plumbing in the buildings of .. `.�.`Z r .. u . ............. at�-........! /....... I . , North Andover, Mass. 2. 2 1` �� Fee. Li .1101-1.7 No..... � ... �, . . UMBING INSR Check # x'992 l bmw a r- Not am ji I Iiaooe pow aHs Ism dWA" B,e aft. Cb. 4CtYee - No ❑ ff you boEos cbedeed Yom, please ieteelype of ooze bl d9B,eapp�apsb�a boot b A labMty Insurance per► ❑ Cow% a of hwbnuft ❑ Bond ❑ OVAEWS NSt1RAltCE MIAIYER: Ion a ms ee doee tent baesgne bo oe corer�10 e ire ed by ch8pw X1,2 of ve lcb Qat i., �d ffiaimy m peno� � Cbm*Oftonv MA..&./S %-it-- --- Arai. ❑ Agent ❑ - By. adrm. � Lio : ra' asatniftbw ftloo wa swa tan UNFOM APPUGATiON FOR PST TO ©O PL U -Now °��h't�;�l �� �' E:�lIeJSIlB��eiC�•tJ�JT R��Ir'8-%+te'1��-adhi�v�E 7%w-.�.�.0�7- cam ❑ Ell Ism p O kwitufondo jM olow:0 Ate❑ Rommllor❑ Rspi 0 plamveso NO l bmw a r- Not am ji I Iiaooe pow aHs Ism dWA" B,e aft. Cb. 4CtYee - No ❑ ff you boEos cbedeed Yom, please ieteelype of ooze bl d9B,eapp�apsb�a boot b A labMty Insurance per► ❑ Cow% a of hwbnuft ❑ Bond ❑ OVAEWS NSt1RAltCE MIAIYER: Ion a ms ee doee tent baesgne bo oe corer�10 e ire ed by ch8pw X1,2 of ve lcb Qat i., �d ffiaimy m peno� � Cbm*Oftonv MA..&./S %-it-- --- Arai. ❑ Agent ❑ - By. adrm. � Lio : ra' asatniftbw ftloo wa swa tan — sit= }es#.sr— ___ l bmw a r- Not am ji I Iiaooe pow aHs Ism dWA" B,e aft. Cb. 4CtYee - No ❑ ff you boEos cbedeed Yom, please ieteelype of ooze bl d9B,eapp�apsb�a boot b A labMty Insurance per► ❑ Cow% a of hwbnuft ❑ Bond ❑ OVAEWS NSt1RAltCE MIAIYER: Ion a ms ee doee tent baesgne bo oe corer�10 e ire ed by ch8pw X1,2 of ve lcb Qat i., �d ffiaimy m peno� � Cbm*Oftonv MA..&./S %-it-- --- Arai. ❑ Agent ❑ - By. adrm. � Lio : ra' asatniftbw ftloo wa swa tan DSA Dewing & Schmid Architects July 13, 2009 30 Monument Square Property Address: #8 Samuel Way Suite 200B Edgewood Retirement Community Concord, MA 01742 North Andover, MA 01845 Tel 978.371.7500 Fax 978.371.3388 Subject: Final Construction Control Affidavit 280 Elm Street South Dartmouth, MA 02748 In accordance with Section 116.0 of the Massachusetts State Building Code, I Tel 508.999.0440 Allen Dewing Jr., MA Registration #4301, being a registered professional Fax 508.999.7709 engineer/architect certify that I was present on the construction site on a regular basis and observed that work was completed in accordance with our Construction www.dsarch.com Documents and the State of Massachusetts Building Code and the requirements of the Town of North Andover and its officials for the construction of the dwelling referenced above. �c����p�VlrrNCT`�c � ?a No. 4301 CONCORD, MA Allen Dewing Jr. 7•/A Date DSA I Dewing & Schmid Architects July 13, 2009 30 Monument Square Property Address: #12 Samuel Way Suite 200B Edgewood Retirement Community Concord, MA 01742 North Andover, MA 01845 Tel 978.3 71.7500 Fax 978.371.3388 Subject: Final Construction Control Affidavit 280 Elm Street South Dartmouth, MA 02748 Tel 508.999.0440 In accordance with Section 116.0 of the Massachusetts State Building Code, I Fax 508.999.7709 Allen Dewing Jr., MA Registration #4301, being a registered professional engineer/architect certify that I was present on the construction site on a regular basis www.dsarch.com and observed that work was completed in accordance with our Construction Documents and the State of Massachusetts Building Code and the requirements of the Town of North Andover and its officials for the construction of the dwelling referenced above. KC'\yI-pEW��,� No. 4301 CONCORD, 5 M ,4 Allen Dewing Jr. 7•/,;� . Date o/