HomeMy WebLinkAboutMiscellaneous - 82 RALEIGH TAVERN LANE 4/30/2018Date./ ®...//.......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........% 5,
..........................................................................
has permission to perform ... ......... ....................
wiring in the building of K . A. ........ 4� ..........
77
at ... le�t,/e .. -17 ...... Llt? ....... PAAA' . �Nlorth Andover, Mass.
. .... ...
Fee.. -L? .......... � Lic. ............... . . . .......
Check #
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Commonwealth of Massachusetts
Department of Fire Services
e
k BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. /0 3 yS
Occupancy and Fee Checked
Lev. 1/07] (leave blank)
i
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
V�All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINTININK OR TYPE ALL MFORMATION) Date:
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) t�Z vc —
Owner or Tenant tA U4 ,.r Telephone No.
Owner's Address 104-1-1 L
Is this permit in conjunction with a building permit? Yes ❑
Purpose of Building
No Check Appropriate Box)
Utility Authorization No.
Existing Service / l/U Lps /2c-, l z j0 V,prts Overhead ❑
New Service Amps / Volts Overhead ❑
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work:
Undgrd Q ---'No. of Meters
Undgrd ❑ No. of Meters
Completion of the following table may be waived by the Inspector of Wires.
Attach additional detail f destred, or as required by the inspector of vrires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEG 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 L.ainsandpenaltiesofperju that th in mation on this application is true and complete.
FIRM NAME:u s �� LIC. NO.:%r��
Licensee: Signature ,y LI NO.: yi 3
(IfapplicXleter "exempt" n the license number line.) Bus. T No.• If - G
AddresAlt: Tel. No.:
*Per M.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.
-y
No. of Total
No. of Recessed Luminaires
No. of Ceil: (Paddle) Susy. (Pa ) " �+ans
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above In -El
Swimming Pool nd. ❑ rnd.
o. o Emergency ig g
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS INo. of Zones
NO..IDetection and
No. of Switches
No. of Gas Burners
nitiatin Devices
No. of Ranges
Tot
No. of Air Cond. Tons
No. of Alerting Devices
Heat Pum
Number
Tons
KW
No. of Self -Contained
No. of Waste Disposers
P
Totals
--
-
-
Deteetion/Alertin Devices
No. of Dishwashers
Space/Area Heating KW
Municipal
Local ❑ Connection ❑Other
No. of Dryers
Hearing Appliances KW
Security
No.. o Devices or Equivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts .
No. of Devices or Equivalent
Telecommunications Wiring:
No. Hydromassage Bathtubs
No. of Motors Total HP
No. of Devices or Equivalent
OTHER:
Attach additional detail f destred, or as required by the inspector of vrires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEG 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 L.ainsandpenaltiesofperju that th in mation on this application is true and complete.
FIRM NAME:u s �� LIC. NO.:%r��
Licensee: Signature ,y LI NO.: yi 3
(IfapplicXleter "exempt" n the license number line.) Bus. T No.• If - G
AddresAlt: Tel. No.:
*Per M.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.
{ ' www.nuws gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #: .
Are you an employer? Cheek.the appropriate box:
1. ❑ 1 aro a employer with 4, ❑ I am a general contractor and I
employees (full and/or part-time),*
2. ❑ I am.a.sole proprietor or partner-
ship and. have no employees
working for me .in any capacity.
[No workers' comp. insurance
required.]
3. ❑ Iain a homeowner doing all work
myself. [No -workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet I
These su&contractors have
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
.c. 1.52, § 1(4),' and we have no
.employees. [No workers'
comp. insurance required_]
Type of project (required):
6. ❑ New construction
7. Q Remodeling
8. Q Demolition
9.Q Building addition
10.Q Electrical repairs or additions
11.0 Plumbing repairs or additions
12.[] Roof repairs
13.[].Other
ection
showing their workett'bompensation
1 Homeowners who submit this ,I MUSE also nil Out the affidavit indicating they are doing allbelow work and then hire outside contractors mustsubmi a new affidavit indicating such.
`tConttactors that check this box must attached an additional sheet showing. the name of the subcontractors and their workers' comp. Policy irfnmmation.
lam an employer that isprovidingP:worhers' compensation insurance for my employees: Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy de'claratiou page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a -
fine up to.$1,500.00 and/or one-year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against -the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. -
Sign
orrect
Siignat ire: Date:
Phone #:
Official use only. Do not write in tl rs area, to be completed by city or town. official
City or Town:
Permit/License #
issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk
6. Other
4. Electrical Inspector 5. Plumbing Inspector
Contact Person: Phone #•
The Commonwealth of Massachusetts
..%I
Gr
Department of Industrial Accidents
Office of Investigations
i•
t
,
Uq //
600 Washington Street
Boston, MA 02111
{ ' www.nuws gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #: .
Are you an employer? Cheek.the appropriate box:
1. ❑ 1 aro a employer with 4, ❑ I am a general contractor and I
employees (full and/or part-time),*
2. ❑ I am.a.sole proprietor or partner-
ship and. have no employees
working for me .in any capacity.
[No workers' comp. insurance
required.]
3. ❑ Iain a homeowner doing all work
myself. [No -workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet I
These su&contractors have
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
.c. 1.52, § 1(4),' and we have no
.employees. [No workers'
comp. insurance required_]
Type of project (required):
6. ❑ New construction
7. Q Remodeling
8. Q Demolition
9.Q Building addition
10.Q Electrical repairs or additions
11.0 Plumbing repairs or additions
12.[] Roof repairs
13.[].Other
ection
showing their workett'bompensation
1 Homeowners who submit this ,I MUSE also nil Out the affidavit indicating they are doing allbelow work and then hire outside contractors mustsubmi a new affidavit indicating such.
`tConttactors that check this box must attached an additional sheet showing. the name of the subcontractors and their workers' comp. Policy irfnmmation.
lam an employer that isprovidingP:worhers' compensation insurance for my employees: Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy de'claratiou page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a -
fine up to.$1,500.00 and/or one-year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against -the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. -
Sign
orrect
Siignat ire: Date:
Phone #:
Official use only. Do not write in tl rs area, to be completed by city or town. official
City or Town:
Permit/License #
issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk
6. Other
4. Electrical Inspector 5. Plumbing Inspector
Contact Person: Phone #•
Date ......
...`r`.?-. '.!�.........
3? trD^•�-`e~ppL TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
This certifies that ............�r� r..:. _.%...........................
has permission to perform .......
wiring in the building of ...•.......:_..............�,.�..;r,r.............................
at ....... �S `7 ........ �.'....:... {..... ..:— Andover Mass.
.......... Lic. No : .-n'C. {S. S�.......... ........' ?-
ELECTRIcALINSPECTO
Check #�_
8293
0
Commonwealth of Massachusetts Official Use Only
01 F8
Department of Fire Services Permit No. 0 C
Occupancy and Fee Checked t_ff�3"0—K
BOARD OF FIRE PREVENTION REGULATIONS [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 IN INK OR TYPE ALL INFORMATION) Date: �S/--e
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) k2 P� I�P�� Avero- Al
Owner or Tenant M f, i,4; a Telephone No. ga_}07f- .9k
Owner's Address 61
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building
Overhead ❑
Utility Authorization No.
Existing Service ),fig Amps /70 l 2140 Volts
New Service Amps / Volts
Number of Feeders and Ampacity
Overhead ❑
Undgrd � No. of Meters
Undgrd ❑ No. of Meters
Location and Nature of Proposed Electrical Work: �r���,
k
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑In- ❑
rnd. grnd.
o. otErnergency 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:
* 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: e&t< 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 cover e 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 ofp rjury, that the information on this application is true and complete.
FIRM NAME: P -I ;trsr All LIC. NO.: t*S" ��
Licensee: � ,,,�t,�,l� ,, Signature LIC. NO.: fdsy&
(If applicable, enter "exemp " in the license number line.) Bus. Tel. No.:
Address: j! idyl,-' -9t S411,� / d:> x•.77 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: $�Sro�
Signature Telephone No.
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
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):! � �' ��`c ,, ��, �� <<y���'� ICr
Address: r S ��,, ,,u 6,�- d- 9
City/State/Zip: �, ,4, �1 Phone #:__ '2'�F fZ 3- . Iry Y i
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
prnployees (full and/or part-time).* have hired the sub -contractors
2. YI 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. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
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. ❑ Plumbing repairs or additions
12. ❑ Roof repairs
13. ❑ Other
*Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: C � qv
Policy # or Self -ins. Lic. #:
Job Site
E
'N
Expiration Date: P%C 0,9
City/State/Zip: & AA4LtnT 14d A
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains qpd penalties ofp5j ry that the information provided above is true and correct.
Phone #: 93t- Lit :? • 16r of "
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 #:
-Location
lslq� 465 Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ AS
Foundation Permit Fee $
CH Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
06 W
TOTAL
MU
gw��g inspector
Div. Public Works
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Department of Public Safety occupanty a fee Checked I
BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1200 3/90 (leave dank)
lug
APPLICATION FOR PERMIT TO PERFORM aIELEZG� 1C�A WOR}
NI work to be performed In accordance with the Mauachu
(PLEASE PRINT IN INK OR TYPE AU
ORliATI N) Date—
City or Town of To the Insp ctor o Wires:
The undersigned applies for a permittoper#orm the klec leaf workdes�ibed below.
Lou tion (Street & Number)
owner or Tenan
owner's Address
Is this permit in conjunction with a building permit: ` - Yes ❑
.�vL
Date `..................................
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ��t
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haspermission to perform�.'........................�.t...,�.:.�............................
wiring in the building Of,/ ::)f.'.:.� .: �- <" ' . ....................
'"� . .`'"�`"" -� ..... , North Andover, Mass.
Fee.........::`................:....,:....................�.,,,...�
............... Li' No A?. ! �i�. . ........ t `-`.........................
....:... ...,.... .....
C/ ELECTRICAL INSPECTOR
04/05/9912.'49
WHITE: Applicant CANARY: Buildingbeet. RAID PINK: Treasurer
OrDILKt
No (Check Appropriate Box)
Authorization NO.
Undgrd ❑ No. of Meters
Undgrd ❑ No. of Heters
Total
No. of,T iNA
U ICenerators RVA
INo. of Emergency Lighting —
Battery Units
FIRE ALARMS No. of Zones
No. of Detection and
Initiating Devices
No. of Sounding Devices
No. of Self Contained
Detection/Sounding Devices
Local tfunicipa1 Other
❑ Connection
ILov Voltage
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Lia iliNO t Insurance Policy including Completed Operations Coverage or, i a substantial
Jr
this
equivalent. hec�YES �leasehave
indicatesubmitted
the typevalid
ofproof
coverage by checking thecappropridte box.
If you have checked , p
INSURANCE,& BOND ❑ CncER ❑ (Please Specify)
kLxpl.raLlull ate
Estimated Value of Ectriqkl Work $ I'veor) _ C
Work to Start y Inspection Date Requested: Rough Final
Signed under the pens sties of perjury:
FIRM NAME
Licensee P4Si
NO.
LIC. NO.
Address r d �7�f/7 4Eyr /�i(1_ .orb/ �_.t11 civ �lt/T�[, No. v
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have th nsurance coverage or is eu `
stantial equivalent as required by Nnssachusetts General Laws, and that my signature on this permit
application waiver this. req�tlrement. Owner Agent (Please check one)'
Telephone No. Pr.I`IITT T TE S _
Slennt ut a of 0-311. 11 -
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or T
NORM , Mass. Date /j- /W- Permit #-,-V- �J��
Building Location_.- 0901 %�Q,%i9h ,fitypr� Owner's Name b—CAA d 6-1',CW DE
C!�
Type of Occupancy
New ❑ Renovation ❑ ReplacerriLkj Plans Su ed: Yes[] No E]
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
f
This certifies that/,-.,
�.
as permission for gas installation ........•.
the buildings of ......... ... "
• • • • • • • • • .. ' ' , North Andover, Mass.
Feer ....... Lic.`No. �:... .
r GAS INSPECTOR
Check #
31- 5',
Check one:
X❑ Corporation
❑ Partnership
❑ Firm/Co.
Certificate #
1862
I 6 meets the requirements of MGL Ch. 142.
+g the appropriate box.
ji Bond [Ilot have the Insurance coverage required by
(permit application waives this requirement.
a Check one:
Owner[] Agent ❑
knowledge and that all plumbing work and Installations performed under ibova-Application are true and accu�te to the best of my
the permit rssu i r this application will n mpliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S. (/ i
Tof License:
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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
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• • • • • • • • • .. ' ' , North Andover, Mass.
Feer ....... Lic.`No. �:... .
r GAS INSPECTOR
Check #
31- 5',
Check one:
X❑ Corporation
❑ Partnership
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Certificate #
1862
I 6 meets the requirements of MGL Ch. 142.
+g the appropriate box.
ji Bond [Ilot have the Insurance coverage required by
(permit application waives this requirement.
a Check one:
Owner[] Agent ❑
knowledge and that all plumbing work and Installations performed under ibova-Application are true and accu�te to the best of my
the permit rssu i r this application will n mpliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S. (/ i
Tof License:
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Plum
Gastdter
City/TownMaster Ucense Number 8 6 9 7
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