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HomeMy WebLinkAboutMiscellaneous - 82 SAUNDERS STREET 4/30/2018cc N_ O O O O O O m Date -2. ...... 1. 1.1.11.4 .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,�- H A 4,.e e This certifies that ...... :5� ..................................... 4—A .......... .................... (2,e r, ov &A e - haspermission to perform .......................................................................................................... wiring in the building of 31.k&.vYL ............................................................................. ............... ... Z ......... (e S ..... S+YZ.A . 4 .... , PAndover, Mass ..... ... ................. .... .... .... ... ... ..... ........ ........ �ee ... ........ Lic. No. 12 -3,33 .................. ...... ................. ............ r ELECMCAL-iN*SPEC`r0R*... Check # � � —L (2) p t54c5 IL4 INA Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. IZ 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 C) 5 7 MR 12.00 (PLEASE PRINT IN HK OR TYPE ALL INFORMATIOA9 Date: City or Town of: NORTH ANDOVER To the Inspector of ices: By this application the undersigned 1. notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant RLlj APV► Telephone No. Owner's Address '-6,L 1519y YWETeis 4 [-1 1-11 Is this permit in conjunction with a building permit? Yes V No ❑ (Check Appropriate ]Box) Purpose of Building thorization No. Existing Service 60 Amps i4 7�Undgrd A90 Volts Overhead ❑ New Service V6 Amps Volts Overhead [90� Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: 1rA5(Vn ' ,S'Z�, 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. rnd. o. o mergency 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 Initiatin Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number Tons.......... KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security c No. of Devices or E uivalent Devis No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications No. o Devices or E u valent OTHER: Atiach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Ele trical Work: , (When required by municipal policy.) Work to St";,4 / Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C GE: 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:) X certify, under the pains and pfe�nnalties o rlury, that the information on tlais application is true and complete. FIRM NAME: �WTr 11���� LIC. NO.: of ^'S&3e f Licensee:�'['j]1 ryl Signature LTC. NO.: (If applicable, er "exempt" in the license number line Bus. Tel. No.:�'-°12$"� -MQ Address: J .0c, i=== 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. ❑ 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 G' 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 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP C ION: Pass Failed Re- Inspection Required ($.) ❑ It. Inspectors Commen s: Inspectors Sign ture: Date: FINAL INSPECTION - Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments - Inspectors Signature: V Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com ki The Commonwealth of Massachusetts Department of IndustriqlAccidihts Office of Investigations qu 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): Address: q �, City/State/Zip-_; Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction _ pdployees (full and/or part-time).* have hired the sub -contractors remodeling E 2. I am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 5. El We are a corporation and its g FJ Building addition [No workers' comp. insurance required.] officers have exercised their 10.❑ Electrical repairs or additions 3111 am a homeowner doing all work right of exemption per MGL 11. [] Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' 13. [i Other comp. insurance required.] *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 Lire doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is thepolicy 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 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 "I under thepains and penalties ofperjury that the information provided abovg is true and correct 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 #: Q 0 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants f 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 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. Anew 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 bum 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 M-assarhusetts Department of IndusWal Accidents Office of Investigations 600 Washington Street Boston} MA 02111 Tel. # 617-727-4900 ext 406 or 1-877MASSAFE Revised 5-26-05 Fax # 617-727-7749 www-Mass,govNia .,e- _-x - Date.. Y. ............... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ....... has permission to perform .................................................................. t4 .................... plumbing in the buildings of ............ 46114 . .................................................... ............... ............. at .... F J j 4-e-� ......... North Andover, Mass. .......... ii� ......................................................................... Fee ...... Lic. No. 1112-1 M4- . ............... ................................................................................. PLUMBING INSPECTOR Check # 17e7 /5-A n / /0 J7 OV\- _____._I .___.J _..._I .__._.._.l ___I J INSURANCE COVERAGE: tJ have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESjfl NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY El BOND M! 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 Q 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 ' pliance with all erdnen rovision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME t � I LICENSE SIGNATUR MPta JP Q CORPORATION 0#©PARTNERSHIP ®# LLC COMPANY NAME �4 p�dANgi �►9 ADDRESS CITY 0)C �2� _ _ .-_ _ _� STATE ®ZIP D ��% Z �—�� TEL FAX CELLEMAIL _ O_�L _C�._ClLi�eAl-Al ty'_.__...._.—..--- ----- --- - ..._ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I MA DATE U A PERMIT JOBSITE ADDRESS $ S OWNER'S NAME P OWNER ADDRESS TEL 7j 3 FAX TYPE OR OCCUPANCYTYPE COMMERCIAL Ej EDUCATIONAL ® RESIDENTIALb4 PRINT CLEARLY NEW: E] RENOVATION: E11 REPLACEMENT: Q PLANS SUBMITTED: YES ® NO� FIXTURES Z FLOOR- BSM 1 2 3 1 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICEL:_J DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIL/SAND SYSTEM =1 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN [ - .._.__ F _._----_l __ _. __.._1 __.._j .___,. ..__..�I ._.__-_ -__1 -1 _ .._._.-E FOOD DISPOSER _i __- _i __.._---.___( f 1 _....___.I .____l ____._( FLOOR/ AREA DRAIN } i _.___..� __— ` I _-_.___{ INTERCEPTOR (INTERIOR) KITCHEN SINK _j= LAVATORY—_ -- ROOF DRAIN SHOWER STALL SERVICE IMOP SINK TOILET TI .._-. _ { _ _ I- 1 ` I _! URINAL WASHING MACHINE CONNECTION f ` _._..__ ` _ .._ . _ I .___.. 1 ._ I ..... _ __. WATER HEATER ALL TYPES WATER PIPING OTHER V­Ifl I I I I II P t I I i r r _____._I .___.J _..._I .__._.._.l ___I J INSURANCE COVERAGE: tJ have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESjfl NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY El BOND M! 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 Q 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 ' pliance with all erdnen rovision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME t � I LICENSE SIGNATUR MPta JP Q CORPORATION 0#©PARTNERSHIP ®# LLC COMPANY NAME �4 p�dANgi �►9 ADDRESS CITY 0)C �2� _ _ .-_ _ _� STATE ®ZIP D ��% Z �—�� TEL FAX CELLEMAIL _ O_�L _C�._ClLi�eAl-Al ty'_.__...._.—..--- ----- --- - ..._ F O z z a �U a w :. � iii k . � t,: tlt moi• �� r, %• . rt Y . •� • S4L u or] z y ❑ >- r� j O ~ _ W W a *b z , w Q co a O � � a O z W� U _I a a Q z w f- w c H z 0 H ccU �W v e .�"t � r e- . '► � t t c k - ' The Commonwealth of Massachusetis Department of IndustriqlAccidints Office of Investigations ' quo 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individud).DC) y,5 P'vJl-,KU4/4 ,w4vtT,Y_l Address: City/State/Zip: Phone #: g 77- Z'93.5' Are you an employer? Check the appropriate box: I$ I am a employer with 2 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 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.]r employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. KRemodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 1I&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. i 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' compensatio in-sunce for m loyees. Below is the policy and job site information. Insurance Company Name:. Z L)Y Tahl `� Sy` `/V ��Ge— • Policy # or Self -ins. Lic. #: W E O 91321 �, A Expiration Date: 3-3 � Zd Job Site Address: 2. SAwgwS Jl 141-AIDd V&c City/State/Zip: MA 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby ce ' nder thepains at(cipenalde ofperjury that the information provided above is true and correct Signature: (,fir 4 Date: 1-23--/Y Phone • ` �� 8�✓�" 4� 3 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 employerI s 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 *a ng not more than three apartmen sand who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwejling house or on the grounds or building appurtenant thereto shall not because of 1uch employment be deemed to be V gmployer." MGL chapter. 152, §256(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 itspolitical 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 numbers) 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 he. , f City or Town Officials « " " T -• Please be sure thatthe 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 Investigai�ons has`to cdfl6ct you'r6garding the applicant. Please be sure to. fill in theTermit/license number which.will.be used as a reference number.:`In addition, an applicant that must submit multiple perinit/license applications in any given year, need only submit one af�davif, "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 of -permit not related to any business or commercial venture (i.e. a dog license or permit to bum 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, telephane and fax number: The Commonwealth ofMassobhus4s Department of lndustdal Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel, # 617-727-4900 ext 406 or 1-877,7MASS.AFB Revised 5-26-05 Fax # 617727-7749 www.wass,govldla r Ct?IVIMOtd1NEALTH OF MASSACHUSETTS i i � i • �.:I C i i • PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE T0: { i JOSEPH R DOYLE ° m 204 MIDDLETON ROAD. , BOXFORD MA 01921-2526 I 11821 05/01/14 148176 11) - ;> 5-- 12 Date . ........... 2'-�5 Vi c, This certifies that has permission to perform C.9 f�?,Vt �7 1�-W t.aa Ut cz..;; wiring in the building of . . . . . . �7 . . . . . . . . . . . . . . . . . . . . . -92--'811 at ............ F - /f, .... North Andover, Mass. F, e 7 -�5L i c. N o. 7.4 . ......... )0 EL&TRICAL INSPECTOR Check# 1 00 —7 11172 r, - Commonwealth of Massachusetts Official Use Only a Department of Fire Services Pe"ItNo.141 7 -L BOARD OF FIRE PREVENTION REGULATIONS [ReV x �yandFeeChecked (leave blank) APPLICATION FOR. PERMIT TO PERFORM ELECTRICAL WORK (PLEASE PRINT bV INK OR TYPEALL INFORMATION) City or Town of: NORTH ,ANDOVER By this application the undersigned gives notice of his or her intention to Location (Street & Number) S e -.l V vt Owner or Tenant c -o n1 1 .. i Owner's Address _ Telephone No. q 7e Date: To the Inspector of Wires: perform the electrical work described below. -io F7.27 � Ts this permit In conjunction with a building permit? Yes [9' No ❑ (Check Apfpropriate Box) Purpose of $uilding L � Utility Authorization No.1 _ -3 � �f l� Existing Service Amps / Volts Overhead ElUndgrd ❑ No. of Meters ew Service a O (3 Amps / Volts Overhead E;— Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �j 2 w 'FLU,,, Cc, rA � � rnk) Com letion o ih e IZ b 4 -TT- No. of Recessed Luminaires Attach additional detail ifdesirecl, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: jG ',;bL � I Z. 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:) X certify, under the pains and penalties of that the information peYjary, on this application is true artd cor p1Ete. FIRM NAME: 3 (T- L E? L, t kF o r J C. LIC. NO.: q � 7 112 . Licensee: J (� SD n h G- Lp •�� Signatur LIC. NO.: (If applicable, enter�exetn t" in the license numb r line,) Bus. Tel. No.; Address: (� a 1�I eG sG &,1N " li-- n Alt. Tel. No.: -q 2& K !� 343 *Per M.G.L c. 147, s. 57-61, security work requires Department ofPublic Safety "S" License—: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) El owner ❑ owner's agent. o owm No. of Cell.-Susp. (Paddle) Fans m a waived b the Ins ector o Wlres. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires d Swimming Pool Above ❑ In- ❑ rnd. grad. o. o mergency ig ng Battery Units No. of Receptacle Outlets � No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches d 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 KVV Local ❑Municipal ❑Other Connection No. of Dryers -2- No. of WHeaters KW Heating Appliances Ky4r No. of No. of Signs Ballasts Security Systems:*. No. of Devices or Equivalent Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Owner/Agent Signature Telephone No. PERMIT FEE: $ r A ' a � ... • FIJIIJL•fCAJ CAL P(/+•( PMT NO.T ��Ju'U��X,I,� JL'D.al�li a•w�� � � BLE �'assec�-- [) • �'aile�l--t } � �e-xns�ectiox�. xe�uixe� ($50.00) � [ � . Tn�peeta�-¢' comm�enfs: . 02&i actors' Pignature - uo inifials) date 3,UNDEI OUND 7NST? C7CZOS�: passed --Z pailecl--j ] Re-iuspection xequirea($60.00).[ Inspectors' comments. �luspectoxs' Signature- no inifials) Date 4.IrxPECzxoz-SES VICE: - Passed— p'aile�i--[ � �e-inspectionxequixe� ($ 0.00) � j � Inspectors' o eph: {Xxtsp actor ' signature - Vito initials} date -ate-inspectioxt requited ($50.00) -I 7 xspectoxs' coznuaai.eats: QhSpedors, Winatoxe -no fiifials) Date D ® OR TAGS .An TO BE MIN) ANDEEFT Off' 91TE IF THU •A.PEA TO BE INSPECTED IS .WOT .ACCEMM AND A. INSPECTION OB SAO 0IN TO BE CHARGED. The Commonwealth of Massachusetts Department of IndustrialAccidints 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): Cj L -e -t c8 co ,s?1 Address: PSP d -go , 4 ' City/State/Zip: �j E n c/ c) ci M r- Phone #: d/7(111�_ - �Sr �i 1> Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its r uired.] officers have exercised their 3. ! 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. ❑ 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. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. 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 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 certlo under the pains l that the information provided above is true and correct na+P /D -- 2_7 - , ,, 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 -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 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 In vestigatious 600 Washington Street Boston, M.A. 0.2111 Tel. # 61.7-727-4900 eyt 406 or 1.-577,7MASS"A.BB Revised 5-26-05 Fay, # 617-727-7749 www-mass.,govfdia N2 9 6 2- 5 Date. % PP.( I 12... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING. This certifies that ..... ........................... has permission to perform . . 14cV..'. . .0. �.. . � ............... plumbing in the buildings of . pi �? .............. at. . North Andover, Mass. ...... A - �- Fee,W! Lic. No.. 01r!� . ......... . 7� - - - c A PLUMBING INSPECTOR Check # 15TL. - — WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK POWNER TYPE OR PRINT CLEARLY CITY North Andover MA DATE 10/12/12 PERMIT # JOBSITE ADDRESS 82 Saunders St. Right Side . OWNER'S NAME Joe Levis ADDRESS 160 Pleasant St TEL FAX OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL NEW: v RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY 1 1 1 ROOF DRAIN SHOWER STALL 1 SERVICE / MOP SINK TOILET 1 1 1 URINAL WASHING MACHINE CONNECTION 1 WATER HEATER ALL TYPES 1 WATER PIPING 1 OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES + NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY � OTHER TYPE OF INDEMNITY BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT f 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 compliance w' al ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME. Mike Capeless LICENSE # 15851 SIG$ARE MP JP CORPORATION # PARTNERSHIP # LLC # COMPANY NAME Boiler Guy/ Mike Capeless ADDRESS 160 A Pleasant St CITY North Andover STATE Ma ZIP 01845 TEL 978-382-1017 FAX CELL EMAIL N2 9626 R S S c"us This certifies that Date. � ?1k � lr� ... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING M,Ve. . . . . . . . . . . ceos ................... has permission to perform . N.CV--l. .................... plumbing in the buildings of rm, �,evl �� ................ at ... S.q..< .Aye . . S, ............ I North �ndyver, Mass. Fee-�4 00. Lic. No.AVZ.5. I . ...... co PLUMBING INSPECTOR Check # k\CR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY North Andover MA DATE 10112!12 PERMIT # v JOBSITE ADDRESS 81kaunders St Left side OWNER'S NAME Joe Levis POWNER ADDRESS 160 Pleasant St TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:. RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES' NO � FIXTURES 7 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK 1 LAVATORY 1 1 1 ROOF DRAIN SHOWER STALL 1 SERVICE I MOP SINK TOILET 1 1 1 URINAL WASHING MACHINE CONNECTION 1 , WATER HEATER ALL TYPES 1 WATER PIPING 1 OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY + OTHER TYPE OF INDEMNITY BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 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 compliance 'th all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. AA PLUMBER'S NAME Mike Capeless LICENSE # 15851 N TU MP JP CORPORATION # PARTNERSHIP # LLC # COMPANY NAME Boiler Guy/ Mike Capeless ADDRESS 160 A Pleasant St CITY North Andover STATE Ma ZIP 01845 TEL 978-382-1017 1 i� FAX CELL EMAIL �ItI 1 Date . �/Ax 7 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ............... ........ has permission for gas'nstallation.�.��..44� in the buildings of .... r. q.vl at ... .................... N rthkndov r Mass. IP0 tru �c H— .... t Fee . ....... Lic. No ... Mb.. ............ GASINSPECTOR Check # Q 0 � 642 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY North Andover MA DATE 11/6/12 PERMIT # JOBSITE ADDRESS 82-84 Saunders st OWNER'S NAME Levis GOWNER ADDRESS 160 Pleasant st, North Andover TEL FAX (— TYPE OR OCCUPANCY TYPE COMMERCIAL[j EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: El PLANSSUBMITTED: YES[] NOL] APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER i ' BOOSTER I i CONVERSION BURNER i COOK STOVE (, 2 I DIRECT VENT HEATER 1 DRYER 2 =1 FIREPLACE 2 l I I FRYOLATOR FURNACE 2 GENERATOR GRILLE 1 INFRARED HEATER i ' LABORATORY COCKS ! MAKEUP AIR UNIT OVEN POOL HEATER i r ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER i UNVENTED ROOM HEATER �W -F-.::] I i WATER HEATER OTHER t ; �w i � 3 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Q NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT SIGNATURE OF OWNER OR AGENT 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 compliance wit Pe ' ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I Mike Ca eless LICENSE # 15851 SI NA URE MP ❑ MGF ❑ JP ❑ JGF ❑ LPGILJ CORPORATION ❑# L= PARTNERSHIP ❑#= LLC❑# COMPANY NAME: The Boiler Guy ADDRESS 160 A Pleasant t CITY I North Andover STATE[ ma ZIP 01845 TEL 978-382-1017 FAX I CELL= EMAIL �� t r b � COR� Aaa::...v CERTIFICATE OF LIABILITY INSURANCE DATE TE (MMIDDIYYYY) 09/24/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Matthews Insurance Agency Inc 182 Parker St CONTACT PHONE I FAX o (978) 681-1112 ; Ac No): (978) 685-3855 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # Lawrence, MA 01843 INSURERA: Atlantic Casualty EACH OCCURRENCE $ _ 1,000,000 INSURED Michael Capeless INSURER B: Arbella 105 Tyler St Methuen, MA 01844 INSURER C GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- LOC INSURER D: INSURER E: i INSURER F: 1'0VFRAr:FC CFRTIFICATF NIIMRFR- REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE A qR WVQ SUBRI POLICY NUMBER POLICY M DDS POLICY EXP LIMITS RIZED REPRESENTATIVE GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F� OCCUR I L143000684 1 08/07/2012 08/07/2013 i w EACH OCCURRENCE $ _ 1,000,000 AREA SES ea occuRENTErrence) S 100,000 MED EXP (Any one person) $ 1.036 PERSONAL & ADV INJURY J S 1,000.000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- LOC PRODUCTS -COMP/OP AGG S 1.000,000 $ AUTOMOBILE LIABILITYCOMBINED ANY AUTO ALL OWNED SCHEDULEDBODILY AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS i HC357357 108/30/2012 108/30/2013 i SINGLE LIMIT IE a accident S BODILY INJURY (Per person) I S 1,000,000 INJURY (Per accident) $ 1,000,000 PROPERTY DAMAGE $ 300,000 Per accident $ UMBRELLA LIAS EXCESS LIAB HCLAIMS-MADE OCCUR x1111463 02/23/2012 02/23/2013 EACH OCCURRENCE $ 1+000,000 AGGREGATE ! $ 1,000,000 DED RETENTION $ $ WORKERS COMPENSATION EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNERIEXECUTIVEj OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N i AJ I 890911 0937696 i 11/17/2011 11/17/2012 I i WC STATU- SET i TORY LIMIT. 1 1 E.L. EACH ACCIDENT $ 100,000 i E.L. DISEASE - EA EMPLOYEE S 100,000 E.L. DISEASE - POLICY LIMIT ; S 500,000 i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) Heating or combined heating and air conditioning systems or equipment, installation, servicing or repair , plumbing /C�TICIlA TG uni ncm r:AUr:FI t ATInFd Town of North Andover North Andover MA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. RIZED REPRESENTATIVE V 1yiSiS-LULU AGUKU I,UKYVKHI1Vrv. All nynu reacrvau. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD m PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER MICHAEL N CAPELESS 105 TYLER ST METHUEN MA 01844-1905 15851 05/01/14 176378 11."'S'I U Date ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Ij This certifies that ....... ....... C ............. 07()W ..5 e .................................. has permission to perform ........... J. A. f .......... ............. wiring in the building of ....... . .................................................. at ........ ?A ....... ...... St. - North Andover, Mas '4 V!:e Fee .3-�..!.O.O. Lic. No. .......... Check # - ///() ... >;ELECTRICA� IN CTOR \ Official Use Only�� Permit No. v (, /j aee«t ad �wBlle Sade�i Occupancy & Fee Checked__ _ _ BOARD OF FIRE PREVENTION REGULATIONS_527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) Date To the Inspector of Wir : Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location Owner or Is this permit in conjunction with a building permit Yes ❑ Purpose of G No f (Check yo 1 E--oW EAsting Service—AZ-2—Amps jj voits Overhead ❑ New Service r Q Amps vits Overhead l/ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Box) Authorization No. Undgmd ❑ No. of Meters r Undgmd ❑ No. of Meters OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = have submitted valid proof of same to the Office YES = NO = if you have checked YES please indicate the type of coverage by checking the appropriate box INSURANCE = BOND = OTHER (Please Specify) (Expiration Date) Estimated Value of Electrical Work$ Work to Start Inspection Date Resquested Rough Final Signed under the Penalties of perjury: FIRM NAME LIC. NO. Lkensee Signature LIC. NO. Bus. Tel No. Address Alt Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) r7�, Telephone No. PERMITTEE $ (Signature of Owner or AgeM /. Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA 2 3 Above ❑ ❑ In ❑ ❑ Generators KVA �} / I No. of Lighting Fixtures Swimming Pool gmd grnd A No. of Emergency Lighting No. of Receptacles Outlets 21 No. of Oil Burners Ba Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No, of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No. of Di sal A No. Pumps Tons KW No. of Sounding Devices No./ of Self Contained No. of Dishwashers Space/A, a Heatin KW Detection/Sounding Devices ❑ Municipal ❑ Other No. of Pryqrs Heatin Devices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Si ns Bailases Wiring T No. Hydro Massage Tuds No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = have submitted valid proof of same to the Office YES = NO = if you have checked YES please indicate the type of coverage by checking the appropriate box INSURANCE = BOND = OTHER (Please Specify) (Expiration Date) Estimated Value of Electrical Work$ Work to Start Inspection Date Resquested Rough Final Signed under the Penalties of perjury: FIRM NAME LIC. NO. Lkensee Signature LIC. NO. Bus. Tel No. Address Alt Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. 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