HomeMy WebLinkAboutMiscellaneous - 85 MILLPOND 4/30/2018-..
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3r°; °TM TOWN OF NORTH ANDOVER A
p PERM'IT -FOR WIRING
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This certifies that........................r.....................................
has permission to perform ....�1 . j'.! ......"..tv.....A/
wiring in the building of .....................! �...f 1.1 ................................
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at ....... �^5...... �.--..k........................... ..Jorth Andover, ass.
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Fee. ........... Lic. No .............. .................. :/.... ;
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2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance-with the provisions of M.G.L. c. 143, § 3L, the !
Y \ permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required i, G.L. c. 143, § 3L.
Permits shall-be limited as to the time ofongoing %struction activity, and may be.deemed-by the -Insp'ector_6f_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
puipose 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.
Jule 8 — Permit/Date Closed: *** Note: Reapply for new permil.
ElPermit Extension Act — Permit/Date Closed: \\
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BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.
Occupancy and Fee Checked
[Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perfotrned in accordance with the Massachusetts Electrical Code C), 527 CMR 12.00
(PLEASE PRINT IV INK OR TYPE ALL INFORMATION) Date: \ OX,\\ \\
City or Town of: To the Inspector of Vires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) '-d e
Owner or Tenant qV Q
Parcel ID:
Telephone No.tV7% 68 re
Owner's Address 3-•V q ,,Q,
Is this permit in conjunction with a building permit? Yes ❑ No Q (Check Appropriate Box)
Purpose of Building X%9.5 Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Cnnmletion ofthe following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Cell: Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- ❑
g d. d.
a oUnits Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of OR Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
of Detection and
Initiating Devices
No. of Ranges
Total
No. of Air Cond. Toa
No. of Alerting Devices
No. of Waste Disposers
P
Heat Pump
Totals:
Number
Tons
KW
No. of Self -Contained
Detection/Alertiny, Devices
_
No. of Dishwashers
Space/Area Heating KW
Municipal
Local ❑ Connection ❑other
No. of Dryers
ry
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water,
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. H dromassa a Bathtubs --]No.
y g
of Motors Total HP
Telecommunications Wirmg
No. of Devices or E uivaient
OTHER: �
Attach additional detail if desired, or as required by the Inspector of wires_
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER❑ (Specify:)
I certify, under the pains and penalties of perjutg', that the informa&n on this application is true and complete.
FIRM NAME:'F,�� NM� t h S@ r i ce5 V., LIC. NO.:
Licensee: -nA fin, U—,,, Signature LIC.NO.: r41662->
(If applicable, enter "exempt" in the license number line) Bus. Tel, No.:x'101 %3\ 7 ��
Address: \ �,tJ %\\ \ r�o�'1ce n q4 A L iv,eoX- r, %'S C-) Alt. Tel. No. Jp\ 6 3q y`%w i
*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
:cqulizd by lava. By ?-iy signature below, I hereby waive this ❑ owner's mettt.
Owner/Agent
Signature T�$1lII SEE, 4 4I
— _ _ _. Telef,:€tt�ry`= X10 -._._., .__..-
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TOWN OF NORTH AND ER
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PERMIT FOR GA INST LLATH
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This certifies that .... ... ........................
has permission for gas installation
in the buildings of . /Ys!'!'; !:� ............................... .
at .............. I orth Andover, Mass.
Fee.. . v.... Lic. No.. G �.`.... E. 'J .)
/GAS INSPECTOR
Check # 1
5977
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type) j
0(I �,Msss. Dau O / Permit #
�.
Building Location A/ l /
/V -P Owner's Name:T,,1,6
Owner Tell (9 % J a V �' oe� 7 Type of Occupancy e�LS �l�G�IYL
New ❑ Renovation ❑ Replacement ❑ Plan Submitted: Yes ❑ No ❑
FIXTURES
Installing Co�mpany Name
,
Address !q0 0 So u-rr // l MA1 N Sr
1-
Check one: Certificate
... .
E=
13Partnership
Business Telephone a 7 & ) Aa3 —130.9', i `Firm/Co. j
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
have a curmnt AablAty Irwrence policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
YasV No O
if you have &6&ed n}, please indicate the type coverage by dwrk lip fie appropriate box.
A liability insurance poNcr,' Other type of indemnity o gond D
OWNER'S INSURANCE WAIVER: I am aware that the fid does not hm the Insurance coverage required by Chapter 142 of
the
Mass. General Laws, and that my signature on this permit appnci* valves thio mquhement
Check one:
Owner D Agent D
Slonature of Owner or Owner's Acent
knowledge and that all plumbing work and Installations perform
rtinent rovlalorrs of the Massachusetts
State Get Code and
By
Type of Uoense:
Title
• -Plumber
•Gas Atter
-Master
Cityfrown
• -Journeyman
APPROVED (OFFICE USE ONLY)
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Installing Co�mpany Name
,
Address !q0 0 So u-rr // l MA1 N Sr
1-
Check one: Certificate
... .
E=
13Partnership
Business Telephone a 7 & ) Aa3 —130.9', i `Firm/Co. j
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
have a curmnt AablAty Irwrence policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
YasV No O
if you have &6&ed n}, please indicate the type coverage by dwrk lip fie appropriate box.
A liability insurance poNcr,' Other type of indemnity o gond D
OWNER'S INSURANCE WAIVER: I am aware that the fid does not hm the Insurance coverage required by Chapter 142 of
the
Mass. General Laws, and that my signature on this permit appnci* valves thio mquhement
Check one:
Owner D Agent D
Slonature of Owner or Owner's Acent
knowledge and that all plumbing work and Installations perform
rtinent rovlalorrs of the Massachusetts
State Get Code and
By
Type of Uoense:
Title
• -Plumber
•Gas Atter
-Master
Cityfrown
• -Journeyman
APPROVED (OFFICE USE ONLY)
ars true and accurate
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Uoense Number d
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COMMt�US
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IN P L U M'R01•'
LICENSEDJAU E' GASFITTE
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DIVISION OFPROFEYSIONAL LICE NSURFIN PLUMBEtt'.AND ;GA•SFITTERS
LICENSED AS ; AN:::-L�^GAS ,INSTALL
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Beverly, MA 01915
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N3URED Xlebuml A. lrysom
RZAt c/o TIS, Inc.
140 S. Mali St.
Xiddltom, U 01949
0 . N . Ly - AN , D,CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER, TMS CERTIFICATE DOES NOT AMEND, EXTEND_*
ALtER-THE!COVERAGE AFFORDED BY THE POLICIES BELOW,,
INSURERS -AFFORDING COVERAGE NAIL 0;
H - MMRA.' National GrAne 12SUrMM Co- 147Es,
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THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED To THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWMWANDINGI
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 POLICES DESCRIBED HEREIN 18 SUBJECT To ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAZ:cLAm$.
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c The Commonwealth of Massachusetts
Department of Industrial Accidents
Off ce of Investigations
60d Washington Street
Boston, MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/OrganizatiorL4ndividual): `✓- C42 2w=2,L C, j
Address: /'-/D Sc L.,7 i�l f�! N ST
M
City/State/Zip: t b17%l�rJ . lll% . 6/iy% Phone #: -Cl 7& 7744 a`2 7,6 0
Are yoy an employer? Check tl�appropriate box:.:.
Type of prnjed (required):
I. 1 am a employer with �_
4. ❑ I sin a general contractor and I
6. ❑ New construction
employees (full and/or part-time).*
have hired the sub -contractors
7
2. ❑ I am a sole proprietor or partner-
listed on the,attached sheet t
modeling
ship and have no employees
These. Isub-comractors have
8. Q Demolition
working for me in any capacity.
workers' comp. insurance.
9. ❑Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
10.0 Electrical repairs or additions
required.]
officers have exercised their
3. ❑ I 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.E] Roof repairs
insurance required.] t
employees. [No. workers,
13.0 Other
c6mp. insurance required.]
i
'Any applicmt that checks box #t meet also fill out the eectiod below showing their workers' compemation policy information.
t Homeowners who submit this affidavit indicating they are doing all'woik and then hire outside contractors must submit a new affidavit indicating such...
iContractor s that check this box must attached an additional sheet showing the name'of the sub-coatracton and their workers' comp. policy information.
1 am an employer that is providing workers'
information.
rtsation insurance for ray employeeL Below is the policy an
fob site
Insurance Company Name:
z'-'-
11 N CJ R' U cJ
Official use only. Do not write.in this area, to be completed by city or town o,8'iciaL
Policy # or Self -ins. Lic. #:
1A C. 9
3 q q:6
Expiration Date: /0//X
AI Q
0
Job Site Address: ! City/State/Zip:
Attach a copy of the workers' compensation polity 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 51,500.00 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 penakies of perjury that the information provided above is true and correct
Sierttature:,,ez
e7 `7,s 4 —
rnone R: z 4 v t - p� . ;.. .
Official use only. Do not write.in this area, to be completed by city or town o,8'iciaL
'Ci or Town:
h 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 #•
Date ../-. ?.. �:. ?-.........
3 TOWN OF NORTH ANDOVER
O D
PERMIT FOR GAS INSTALLATION
This certifies that ..P/. 3 C.I.! .... !11.. f` .....................
has permission for gas installation .. ! 1 < :: ! c . -s .............
in the buildings of .....-................................. .
at ...�� ... ........ ............ . North Andover, Mass.
Fee. Lic. No..- -..........
`GAS INSPECTOR
Check # � � `f � /
38 co8
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MASSACHUSETTS
2,,^r
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTIN' G
(Print or Type)
c NORTH ANDOVER &Aass. Date 14
uilding Location d Permit 3
t
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•� Owners Name �� ICs rel
• New Renovation D Replacement p Plans Submitted D
FIX- UR=c
I
(Print or
Installing
Address
Type)
Com any
N a m e l %4
G)0
Check one: Certificate
Q Corp.
Partner,
Firm/Co.
Business Telephone: COW -L/1, 1 - D
Name of Licensed Plumber or Gas Fitter 9>' 0. PR.� '
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy EZ3 Other type of indemnity E] Bond ED
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 coverages.
Signature of owner/agent of property Owner F] Agent F7
1 hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that aU plumbing worst and Installations performed under' Permit issued for this application will -be in compliance with all Pcstlnent
provisions of tho Massachusetts Slate Cas Code and Chapter 14: of tho General Law&. _.
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICENSE: P
Plumber
Gasfitter. Signature of Licensed
Master Plumber or Gasfitter
Journeyman lay6(
License. Number
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2ND FLOOR
3RM FLOOR
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4TH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
(Print or
Installing
Address
Type)
Com any
N a m e l %4
G)0
Check one: Certificate
Q Corp.
Partner,
Firm/Co.
Business Telephone: COW -L/1, 1 - D
Name of Licensed Plumber or Gas Fitter 9>' 0. PR.� '
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy EZ3 Other type of indemnity E] Bond ED
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 coverages.
Signature of owner/agent of property Owner F] Agent F7
1 hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that aU plumbing worst and Installations performed under' Permit issued for this application will -be in compliance with all Pcstlnent
provisions of tho Massachusetts Slate Cas Code and Chapter 14: of tho General Law&. _.
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICENSE: P
Plumber
Gasfitter. Signature of Licensed
Master Plumber or Gasfitter
Journeyman lay6(
License. Number