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Home My WebLink AboutMiscellaneous - 83 OLD FARM ROAD 4/30/20180 0 w Q 0 0 rn 0 0 0 0 b Date.... T TOWN OF NO,RT /NDOVEER PERMIT FOR PLUMBING "."4cwus This certifies that ............ :4� ..... has permission to perform .......... plumbing in the buildings of at.. ��6rth*'A* n*d**ov*e*r',* F '7' 7'Lic. ........ ee. . PLUMBING IN 10EC OR Check # 2/,72J 41 7796 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location 3 0 ! D /��rM /'� J] Owners Name p �r ,..� = Date 7/374, �� vo� Permit # Amount Type of Occupancy �eS j�e•,, `„t New Renovation Replacement Plans Submitted Yes1:1No (Print or type) / / Check one: Certificate Installing Company Name zz 'eu' /�/uvt (��wr ��%p;,s. ” Corp. Address - % C/rel11 / Partner. . C..- ss .iss I elephone rm/Co. b Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massach ate Plumb' e and Chapter 142 of the General Laws. By. 012 b u i iumDe Type of Plumbing License Title City/Town icense 114 umber Master ❑ Journeyman j�- APPROVED (OFFICE USE ONLY LL._II 40 ! -33 --------------------W---t • / ! 5--------------------•---- • • ! ---------------- MMM ------ =--------------�-----W-- 1 ! ------------- ! M--------- ----- ---- ---t !t --------------------•---� -- (Print or type) / / Check one: Certificate Installing Company Name zz 'eu' /�/uvt (��wr ��%p;,s. ” Corp. Address - % C/rel11 / Partner. . C..- ss .iss I elephone rm/Co. b Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massach ate Plumb' e and Chapter 142 of the General Laws. By. 012 b u i iumDe Type of Plumbing License Title City/Town icense 114 umber Master ❑ Journeyman j�- APPROVED (OFFICE USE ONLY LL._II -/, -, f- �')'? Date..... . ....................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING niscertifies that ............................................................................................. has permission to perform J'—, ..................... wiring in the building of IL-1 ...... ............ at .... ...... 621-eell) ... . ....................... 25F—! .... . . . ......................... . North Andover, Mass. ...... ........ Fee........... Lic. No . ............. .......... . .................... ......................... ELECTRI�AfINSPEcrOR Check # 8 2 36 9Eh-N Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. d26 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked_ [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN AW OR TYPE ALL INFORMATION) 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)_1 3 0/at /� 0rrnPli Owner or Tenant N. AVdvA Telephone No. Owner's Address A rv►_0 n e u 1. Is this permit in conjunction with a building permit? yes C Purpose of Buildinge� No ❑ (Check Appropriate Boa) -# Utility Authorization No. Existing Service LA6 Amps1 � l 7i a Volts Overhead ❑ Undgrd New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1�1 T�(IQ h (2 OU)» a Ipn✓1 nw Y_ Alv.e No. of Meters No, of Meters ---•-�•• •-•......� 1 aelat, v aesirea, or as required by the Inspector of Wires. __� Work to Start: Estimated Value of Electrical Work: (When required by municipal poIicy.) 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 cove is m force, and has exhibited proof of same tom the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER (Specify:) ZUF'lr(',�!, ❑ (Spec' I certify, under the pains and penaltiesperjury, that the information on this application is true and complete. FIRM NAME: -LIC.NO.AadooAq Licensee: A 5-aMe ag N %O W Signature LIC. NO.: (If applicable enter "ez t " in the li ens umber !i .) Address: G AS d j (, Bus. T e L No.: - Z -0 ?3 *Per M.G.L c. 147, s. 57-61, security,work re uues „ „ Alt. Te1. No -:Q 9- - rr 3 q epartinent of Public Safety S License: Lic. No. • at the Licensee does not have the liability insurance coverage normally WaiveLIMUDY s req e c ec reqUW, er owner's agent Owner/Agent Signature Telephone No. FF.F• !C 13 The Common wealth of Massachusetts k� ( Department of Industria! Accidents Office of Investigations it I 1"'" 600 Washington Street ,'aaa f Boston, MA 02111 { j www nwsrgov/dia . Workers' Compensation lwkr'ance Affidavit: Builders/ContractorsMectriciang/Plumbers rtnfiennt Tnfn.•..,..f:.... Name fBusiness/O rguization/Individual), --R d n atl Address: (2 t r.P, ,'�pvl 'R+ City/state/Zip Lo 61'76d Phone M Insurance Company Name: Policy # or Self=ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the .workers' compensation poficy 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 tilos 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 y against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigatio of e DIA for insurance coverage verification. I do that the information provided aboye is pie and correct YY}�ss use only. Do not write in this area, to be completed by city or town ofciaL City or Town: _ Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. 6. Other Plumbing Inspector Contact Person: Phone #: Are you an employer? Check th appropriate box: }. ❑ 1 aro a employer with 4 ❑ I am a general contractor and I [): Type of prefe7)n employees (full and/or part-time).' 2,� I am have Hired the sub -contractors 6 New co a.so}e proprietor or partner_ listed on the attached sheet; = 7. ❑ Remode ship and have no employees These suit -contractors have 8. ❑ Demo}it working for me in any capacity, [No workers comp. insurance p workers' comp. insurance. 5. ❑ We are a corporation and its . 9• 01 Building required.] I air a homeowner doing officers have exercised their 10.❑ Electricadditions3.❑ all work right of exemption per MGL 11.❑ Plumbinadditions myself. [No•work=' ' comp. insurance c.. L52, § 1(4),'and we have no 12.M Roof repairs required.] t employees. [No workers' 13.❑ Other comp. insurance required.] Any epplicattt that checks boat # I must also fill out the section below showing their workerd' compensation policy information t Homeowners who submit this affidavit indicating they are doing atl work and then hire outside contractors must submit a new affidavit indicating 4contractors that such. check this box must attached an additional sheets showing the [tame of the sub+conttactots and their worker;' comp. Policy itifarrnatroa. I fo an employer that..is pro ng workers' compensation 'nsurance for ray. employees: Below is. the Policy inforntation. p hcy and job site Insurance Company Name: Policy # or Self=ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the .workers' compensation poficy 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 tilos 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 y against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigatio of e DIA for insurance coverage verification. I do that the information provided aboye is pie and correct YY}�ss use only. Do not write in this area, to be completed by city or town ofciaL City or Town: _ Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. 6. Other Plumbing Inspector Contact Person: Phone #: Information a tnd Instructions s 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, assodiation, corporation or other legal entity, or any two or more ofthe'foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or t ustee of an individual, partnership, association or other legal entity, employing empioyees. '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 numbers) 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 cavy 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 numberlisted below. Self. -insured companies should entertheir r 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 vvilI be used as a reference number. In addition, an applicant that must submit multiple permit/licame 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 parson 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. C The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 0.2111 Tel. # 617-7274900 ext 406 or 1-$.77-MASSAFE Revised 5-26-05 Fax # 617-727-7744 www.mass.gov/dia S. Y- 16-6e Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ 15V....PPY Zvc- I.............................................................. has permission to perform ...... .... / .... wiring in the building of ::T ............ M,-, ve) V ........ ; ............. ;'411-1-1-1-1- .... —11 ........ at .... 73 .... OK4.e��k ... Wf y .......... . North Andover, Mass. Fee ... 3 .......... Lic. No. ................ 0,'&1Az4eo4c— ................... ELECMCA L INSP ECIbR Check # 0? e7l 6 (r; 7 r`1 Cammonweall o/ Mas:jac% ese�is OCliciul Use Otrly k �e�arinean� a�}ire �ervicas PCrnut Nu. / BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/991 (leave blank) APPLICATION FOR PERPAIT TO PERFORM ELECTRICAL WORK All work to be perforn;cd in accordance with the Nlassachusctts Electrical COdc (NIEC), 527 CINIR 12.00 (PLC:ISE PRINT LV INK OR TYPE :ILL 1N1-'01V,1,1770it) Date: b 1? //G � 0 C City or Town of: MD A Aino (,A&. To the hisl)ector of rres: 6Y By this application the undersigned gives nonce oI his or her intention to perform tl„e electrical work described below. Location (Street & `iunlber) 8; �� •.�� ` f,� Owner or Tenant �% Telephone No. Owner's Address Is this permit ill conjunction with a building permit? Yes ,❑ No ❑ (Cluck Appropriate Box) Pul"pose of Building C)hi-t.I/(ad Utility Authorization No.Existing Scrvice :� Amps / faits Overhead ❑ Ulid„ b `!Sc..r�� / id ❑ No. oftlIctcrs . L ” icQ / Amiss / Volts Oti•cr hc::d ❑ Uudgrd ❑ r\'o. of INieters: Number of Feeders and Anipacity Location and Nature of Proposed Electrical Work: culunletfan offlio inll....•l.,.. i,.l./ No. of Recessed Fixtures No. of Ccil.-Susp. (Paddle) Falls ,,, , • �� „arti•en ov ttre Drs error or wires. IN 0. °f Total 165 Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators hVA - -11 No. of Lighting Fixtures ISivimminc, Pool Above ❑ III- ❑ b grad. rnd. t o. o mIy cg Itulg Battery Ullits FIRE ALARDIS No. of Zotles No. of Receptacle Outlets No. of Oil Burners No. of Switches No. of Gas Burners 1`to. of llctectio❑ and Initiating Devices No. of Ranges No. of Air Cond. Total Tons INo. of Alerting Devices No. of Waste Disposers Heat Pulllp iYumber "Tons ' --- I{\V of'Scli"-Contairlcd --� _ Totals: �:Vo. Detectiotr/Alerting Devices No. of Disll}s astlers Spacr/Area Heating KlV Local [:]1tilunicipaI Connection F-1 Other No. of Dryers Heating Appliances IL\y Security Svstcnls: No. of 1 No. of Devices or E uivalent -W No. of No. of Hee K Data .,tiring• Heaters Si�rls Ballasts , (o. of Devices or E uivalent No. Hydromassage BathtubsNo. of i\lotors Total ITP Telecommunications `Virm -. No. orDeviccs or E uivalent OTHER: AUucn aaamairar aetad y desired, or as required by the Inspector of Wiles. 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" covera�_e or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuinv office. CHECK ONE: INSUR \NCE ET BOND ❑ OTHER ❑ (Specify:) Estimated Value of Electrical Work:* (When required by municipal policy.) (Expiration Date) Work to Start: Inspections to be requested in accordance with NIEC Rule 10, and upon completion. I certify, udder t pains acrd penalties of perjury, that the information oa this application is true and complete. FIIZINI tNAINIE: Buddy Electric Inc LIC NO : 12017 A Licensee: Vincent B. Ienders QTR Si -nature/ � L1c23684 E (lf applicable. enter •'a.rc upl "• in Nle license nra.unber line.) Bus. Tel.. N 9 _ 4 4 Address:24 Col as -- Dr Tri Anr�nvPr Ma n1R45 6 Alt. Tel. No.: OWNER'S INSU 1:A.NCE WAIVER: I am awarc that the Licensee does not lraue the liability insurance coverage normally required by law. By my signature below, I hereby %vaive this requirement. I am the (check olte) ❑owner ❑owner's a�,ent. 01Yner/Agcut Signature Telephone No. Pf�R:1IIT FEE: S