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HomeMy WebLinkAboutMiscellaneous - 886 SALEM STREET 4/30/2018Date .Z.—.1 .... .. Z.T—.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ 7 ........... *7 ........................... .. .. .. .. .... ... ............. has permission to perform .... ........... C. I ........................ wiring in the building of ......... re —/ ........................................................ at .... ?n ...... ......... North AUdove Mas Fee..S'5 .... t� ..... Lic. No. fj LEMICAL Check I 10573, C.,mawt waA v/ Ma63acLA Oficial Use Only c� cc77Permit No. % 1'2 S a(JeparEinett� o�_}ire Servke� Occupancy and Fee Checked BOARD OF FIRE PREVENTION' REGULATIONS[Rev. 1/07] eave 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: City or Town of ,NO2Th' 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). Re 6 SWC, t/#% S Owner or Tenant Owner's Address Is this permit in conjunction with a. building permit? Yes Purpose of Building �;//)EJ4 Existing Service al% Amps gd fdk Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: &J M dd Telephone No. No Q (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd E No. of Meters _L Overhead ❑ Undgrd ❑ No. of Meters 0 6- ILIZA1 C amnletion of the following tnhLe mnv hw wnivod by tho &vrwemr ofW7rPC No. of Recessed Luminaires q No. of Ceil.-Susp. (Paddle) Fans o. of Total Transformers KVA No. of Luminalre Outlets No. of Hot Tabs Generators KVA No. of IAaminaires Swimming Pool AboveIn- ffnd. ad. o. o mergency. Batt Units No. of Receptacle Outlets Q No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas. Burners o: of Detection an Iniftati Devices No. of Ranges No. of Air Cond, Total Tons No. of Ale Devices � No. of Waste Disposers Heat Pimp. Totals:1 . umber Tons lKW No. ofSelf-Contained Det '2 "ices I I No. of Dishwashers SpacdArea Heating KW Local ❑ E7 Other No. *of Dryers Heating Appliances Imo' Security ems: No. of Devkm or FAinivalent No. of iter; Heaters No. of o. of Sim Ballasts Data VI"icittgi No..of Devices or uivaleat No. Hydromassage Bathtubs No. of Motors Tota[ HP T ommarucatioas . No. of Devices ar eat OTHER: . Estimated Value of Electrical Work: Awadi a*Wonaldetail jfdakvA orasnquirrd by the Inspe"ofirwa (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. alEC:K ONE: INSUMkIkE ❑ BOND p.. OTHER Cl (Specify:) I mAW, under the pdm twdPwatda-ofperiaY', Md dte infotrturdon On this app&afion Is trtte and murk a FIRIMNAME: Chant -Electric Inc LIC. NO.: A 1 1 9 5 _ Vincent Chant Signature fid UC NO.: Rf�k �� "exempt" in the license raan6er line) Bus. Tel.No =7_81- 0 n - 5 9 4 9 Address: _ 4 Berry Bush Road Littlton, MA01460 Alt.TeLNo.:-9."78-486-8826 ' *Per AG.L. c.147, s. 57.61, socut* work acquires Department of Public Safety "3" License: Lic, No. OWNER'S INSURANCE WAIVER I am: aware that the Uomtsee does not have the liab' ' insurance coverage taw. 8 �y vexage nornhally r6quired by y my signature below, i hereby waive this requirement. I am the (check one O owner flowwVsagent pwowlAgent Signature Tdephone No. PERMT FEE. $,,r a I i Date ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .........��lq�:. 7.......... i�.......... .................... ... .... ... ....... .... has permission to perform ........./....... (t4� #.T,-2< ....... wiring in the building of ..........E-0 ... Y ................................................... at ..... V. ......... 5.2 . . ...................... North Andover, Mass. 4� �-R� .. . .... . . .... . Fee...? ... Lic. No. 411f -.5 ...... . ICAL INSPECTOR NSP . Ec . -roR .. ...... .... Check # 10696 �L\ t,onnwncvea a� l�a9¢ . aUepa,�irzet� a��iire .:�ervice9 BOARD OF FIRE PREVENTION REGULATIONS Official Use/Only Permit No. Occupancy and Fee Checked [Rev. 11071 eave 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 PRRVT IN INK OR TYPE ALL INFORMATION) Date: 3— / / ?i City or Town of: n%d�, j- t}A told', X To the Inspector of Wires: By this application the undersigned gives notice of his or her intention t� orm the electrical work described below. Location (Street & Number). ?Cf,� Owner or Tenant 4f �Py Y Telephone No. Owner's Address c5 J17 J� Is this permit in conjunction with �ag. building permit? Yes (g No Q (Check Appropriate Box) Purpose of Building 12ty Utility Authorization No. Existing Service dod Amps /o2Q 1,7,0 Volts Overhead ❑ Undgrd No. of Meters / New Service Amps ! Volts Overhead Q Undgrd Q No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:�W--s; 1-1, '9- W 14,6 W r51-f/VfA14/dX Completion of the followinztabk may be waived by the InsnecterofWwes. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans d AMAad&dond dwd i, fdesire4 or as req red by the InspedorOjWir-t Estimated Value of Electrical Work:of 0,j d , (When required by municipal policy.) Work to Stam 3 ;s =l l q*Wous to be requested in accordance with MEC Rule 10, and upon completion. INSURANMCOVERAGE: Unless waived by the owner, no permit for the performance of electrical worst may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equNdent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: JNSUMUkE ( BOND Q.. OTHER [] (Specify:) I mnW, ung' dmpains tmd pwddes-ofpetyary, that the information on this appfeafon is tate and coiWleie, FMMKAME: Chant -Electric LIC. NO.: Al 195 Licensee: Vincent Chant Signature LIC. NO.: (1, fapplioable, emer "exempt" in dw Ucetrm nwnber ftm) Bus. Tel. No.: 7 $1- A n - 5 9 4 9 Address: 4 Berry Bush Road Littlton, MAO 1460 Alt.TeLNo.: §j8-486-8826 *Per AG.L. c.147, s. 57.61, security ity work rNuires Department of Public Safety "S" License: Lia No. OWNERS INSURANCE WA i m. I am aware that the Licensee does not have the liability insurance coverage normally ftVired by law. By try signature below, I hereby waive this requirement. I am the (check one) Q owner Q owner's agent awn tura PERMIT FEE• $ Signature Telephone No. , NO. TransTotal Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA - No. of Luminaires Swimming Pool Above Q In- Q d. ad. o. o mergency. erg Batt 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 !1!99ft Devices No. of Ranges No. of Air Cont. TOtat Tons No. of Ale Devices No. of Waste Disposers Heat Damp. Totals: amber Tons ICW o. of stained Detection/ No. of Dishwashers Space/Area Heating KW Mcievices Local Q. r Q Other Nor.'of Dryers . Heating Appliances KW Security ems: No. of Devices or Equivalent No. of Wit& ICQV Heaters No. of No. of signs Bad Data War. No..ofDevicesor Equivalent No. Hydromassage Bathtubs No. of Motors Total HPT ecommurtiications . No. of Devices or FAralvalent OTHER d AMAad&dond dwd i, fdesire4 or as req red by the InspedorOjWir-t Estimated Value of Electrical Work:of 0,j d , (When required by municipal policy.) Work to Stam 3 ;s =l l q*Wous to be requested in accordance with MEC Rule 10, and upon completion. INSURANMCOVERAGE: Unless waived by the owner, no permit for the performance of electrical worst may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equNdent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: JNSUMUkE ( BOND Q.. OTHER [] (Specify:) I mnW, ung' dmpains tmd pwddes-ofpetyary, that the information on this appfeafon is tate and coiWleie, FMMKAME: Chant -Electric LIC. NO.: Al 195 Licensee: Vincent Chant Signature LIC. NO.: (1, fapplioable, emer "exempt" in dw Ucetrm nwnber ftm) Bus. Tel. No.: 7 $1- A n - 5 9 4 9 Address: 4 Berry Bush Road Littlton, MAO 1460 Alt.TeLNo.: §j8-486-8826 *Per AG.L. c.147, s. 57.61, security ity work rNuires Department of Public Safety "S" License: Lia No. OWNERS INSURANCE WA i m. I am aware that the Licensee does not have the liability insurance coverage normally ftVired by law. By try signature below, I hereby waive this requirement. I am the (check one) Q owner Q owner's agent awn tura PERMIT FEE• $ Signature Telephone No. , Date ...; : p` „Io,eye pL TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .. al.7..,l:Xw-o. 1, -It/f .................. has permission for gas installation ... � ................... in the buildings of/ .............................. . at .... ....... , N4q,h An ver, Mass. Fee. ,-jq?.. Lic. No. / % ZS . ... ... ....:.. GASIR Check # 60 f MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town:. &A MA. Date: 62423 Zig, Permit# Building Location: Owners Name: k-40-&( Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential to New: [I Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ PYTI IRFC - - - - - - - - -� - W - Cd Z IX IX0 W W x 2= o: Il] l4 O Z t— F- W C7 —1 } 0 Z CO) 0 M W IY 0z 9 W W Z o m w O ED � W W p O 0 Q =) > u, U z W W � C9 ~ � W Co 0 Q w W I— oILL _ > V W Z O Z } to -j Iw— Q 1— Q O m Z w J O (� z u_ 0 lA x F- W > W Z W W I— x O W M Q 0 0 O u_ O r it O w x W z Q> � O O a O CE W Z H>>>� Z W Q H 0 SUB BSMT. BASEMENT 1 FLOOR 2NuFLOOR Vu FLOOR 4 FLOOR 5 FLOOR 6 FLOOR a 7 FLOOR 8 FLOOR Check One Only Certificate # Installing Company Name: �%� P-� j-} .� n ❑ Corporation Address:y i��� City/Town: State: _M ❑ Partnership Business Tel: `l7F--41fp- dtla6 Fax: ❑ Firm/Company Name of Licensed Plumber/Gas Fitter: L -,u' INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes a No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ®, Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE 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 Signature of Owner or Owner's Agent Owner El Agent El By checking this box ❑; 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: �VL 5�O Plumber Lj Title ❑Gas Fitter Signature of Licensed P umber/Gas ber/Gas Fitter ❑ Master _ Cityfrown MJourneyman License Number: �? 7�l o� `I APPROVED (OFFICE USE ONLY) ❑ LP Installer The Commonwealth of Massachusetts Department of Industrial Accidents Offiee of Investigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Onliennt Tnfnrm.f:..- Name (Business/Organization/Individual): - - - - . Address: A3 q __dAO(1.� ,--t- - City/State/Zip: � ��p Phone 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).*' 2. I am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheet. I ship and have no employees These sub --contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing officers have exercised their right all work 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.] *r ny ay'ahCant P,L-L checks box *1 must also fin out the section below: -o Type of project (required): 6. ❑ New construction 7. ® Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions .11 - El Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other T matiam Homeowners who submit this affidavit indicating they are doing all work and then hire 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: 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct A..,-/? n Official use only. Do not write in this area, to be completed by city or town offcial City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 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 dwellinghouse_of another who -employs-persons to. do_mainttnance, construction or repair work -on -such dwelling houseor 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 coinpliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub=contractor(s) name(s), address(es) and phone number(s) along with their 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, r eturned to the. city or town that the applirati3n for the per, :ait o� hvense is being requested, not fn-- Depa_rtmont 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 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 Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77 MASSAFF, Fax # 6.17-727-7749 Revised 5-26-05-wwv%mass..gov/dia 0067 + 14U Date .......... .. 3 ... . ........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... .......... . ............................. has permission to perform ......... wiring in the building of.. ............................. at ..... ................... North Andover, Mass. Fee .... ?. ..77 Lic. No./k'. I .., ............... ELECTRICAL IN PE R Check # Commonwealth ®f massachusefts official Use Only ' Department ®f Fire services Permit No. ��____ BOARD OF FIRE PREVENTION REGULATIONS V. 110ncyaudFeeChecked [Rev. 1/07] `----- leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL W All work to be performed in accordance with the Massachusetts Electrical Code ®�� (PLEASE PRMTIN1NK OR TYPEALL INFO TIOA9 Date: (11 0), 52� CMR 12.00 City or Town of: $: , By this application the undersi ed. gives no ' e of his or her intentionto perform the electrical workTo the In ec r of tescribed below. Location (Street �& Number) a � r,-, -, M _ r- --- Owner or Tenant�n��T� Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes EJ No EJ BLDG PERMIT Purpose of Building #. Existing Service Amps Utility Authorization No. '6rolis New Service / Overhead ❑ Undgrd ❑ No. of Meters Amps Number of Feeders and Ampacity / _yolts Overhead El , Undgrd ❑ No. of Meters Location and Nature o Proposed Electrical Work: Com\ C -04,t >i \ No. of Recessed Luminaires Completion of the following le may be waived by the Inspector of Wires. No, of Ceil.-Sus . No. of p (Paddle) Fans No. of Luminaire OutletsTransformers No. of Hot Ibbs Total. KVA No. of Luminaires Swimming pool Arn v E]In Generators KVA o. o mergency ig g tm No. of Receptacle Outlets rnd. No. of Oil Burners Baite Units No. of Switches FIRE ALARMS No. of Zones No. of Gas Burners No. of Detection and No. of RangesInitiatin No. of Air Cond. Total Devices No. of Waste Disposers Tons Heat Pump Number Tons KW No. of Alerting Devices ' No. of DishwashersDetection/Alertina Totals:..._ .............................. ................... No. of Self -Contained Devices Space/Area HeatinK g w Local ❑ Municipal ❑ Other No. of D ers rY Heating Appliances KW Connection Security Systems:* No. of Water Heaters ' No. of No. of Devices or Equivalent No. hydromassage Bathtubs Si s as BallBal asts No. of Motors Data Wiring: No. of Devices or E uivalent ' Total HP Telecommunications Wiring: OTHER: No. of Devices or E uivalent - Estimated Value of Electrical Work: 11 « Attach additional detail if desired oras required by the Inspector of Wires. (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 unle the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The ss undersigned certifies that such cover a is in force, and has exhibited proof of same to the vermit issuing office. CHECK ONE: INSURANCE I cert, under the pains and penaldesOofpe❑ Oha�h information on is i Zi a o �� `'IRM NAME: q ` (�` f r ` ' � PP trate and completes Licensee: ki t LIC. No... O'l Signature (Ifapplicable, enter "exem " in the li a number line.) LIC. NO.: ck Address: wed- Li t`C.l ^ 1 , .. I Bus. Tel. No.: q 7$ 6 6 9, XPer M.G.L. c.147, s. 57-61, security work requires Department of Pu 'c Safe S Licen Alt.Tel. No.: Gt 7 O8 g �q� OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability ins uran a ovO.: normally required by law. $rement. I y my signature below, I hereby waive this requiaone) 0 owner El owner's agent. Owner/Agent m the (check Signature Telephone No. PER RWT FEE. $� ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL [2- FINAL INSPECTION; Passed — Failed — [ ] Re -inspection required ($50.00) - [ ] L tinspectors• Ntgnature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF T]JE AREA, TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. R J The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston, MA 0211.1 UV www.mass.gov/dia Workers' Compensation InsuxanveAffidavit: Builders/Contractors[FIectriciaus/Pluma.bers Applicant Information ]Please Print Legibly NaMO(B.usiness/Organization&dividual): Address: City/Mate/Zip: Phone Are you an employer? Check the appropriate box: ' 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (fulland/orpart time).* have hired the sub -contractors 2. ❑ lam a sole proprietor or partner- listed on the attached sheet. r ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp, insurance 5. ❑ We area corporation and its required] officers have exercised their 3. ❑. I am a homeowner doing all work right of exemption per MGL myself, [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp, insurance required.] Type ofproject (required): 6. [] New construction 7. ❑ Remodeling . 8. 0 Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other —Y aypucanr rnar cnecxs ooxff.t must also mi outuie section below showing their workers' compensation policy information. 7 Homeowners who submitthis affidavit indicating they are 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. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: rob 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 ofup to $250.00 a day against the violator. Be advised that a copy ofthis statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Hereby e ertify un der the pains and penalties ofperjury that the information provided above is Prue and correct. S_ ignature• Date Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License issuing Authority (circle one): x. Board of$ealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other ContactPerson: Rhone #: Date. .7//1Y..1....... . .NORTH °f1'40. o= TOWN OF NORTH ANDOV R r • PERMIT FOR GAS INSTALLATION This certifies that.. ,�.�. .. ,��.t?! .� �1 ................ has permission for gas installation ..U.. R. H....... ........... in the buildings of 15' Y .............................:.... at ..... ff�. f -r `:�......... North Andover, Mass. Fee)?e ' ... Lic. No..Yb.©/... .�.._...... . AS INSPECTOR Check # 3 t/, ?- 4.4A9 44A9 AM r3 1l 6: =_ ;3 � U # i3 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING CitylTotiirrl d! R ±6611 Permit# rBuilding pI� F �r Owners Name. 08g'� s i e� {,� 1'.!x :1 y 1, r+ a Rxz'�[ { tir" a ,t¢hF ., a- •''� 1 { LI Type Of Occupancy - Commeraa 4° Edu tlonl _ ' Industrial; InsbtuHonaCj Resldenbal I i New o Alteration:❑ Renovation Replacement:a =Plans Submitted: Yes No • - o --- -- --..111_1__, --- --.F .._. _.. ,1111.,, ..o.o..o a........v....auv.....a.a auemnupu wi a umtwr regaramre vu g [ms appncaaon am ana ' accurate to the best of my Knowledge and that all plumbing work and Installedoii6 p'erknned under the permit Issued for this appik atlon ,will be In compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter,142 of the General Laws. �.. Type of License: , By Plumber v #... ritiel Gas Fitter ig ature of Licensedlumber/ Fitter i Masser { � ;• C4rN ;,ri r. Journsyeran License Number/0077 APPROVED OFFICE USE ONL LP Installer. , ,; M FIXTURES_IU _ IU W N In = O W W (O j y ;z ® Z x W Z 0 0 Z J } O .� o: O# ; N ,� . 0 O � w W oC v� v w w � m O 0 ::� H ,a 'O i° , k r� o W -C1 1z 4c Z OW 0 Z W W� W � cLLW S 'm W z>0- Q` , - cJ� o d � W. SUB BSMT. BASEMENT .� i �+ _:�'�� 'w"yr �. it t�: ., t t "N i Y a. •F^^f. ,,i• !� `{t . � i ..� j 151 FLOOR wv I� fL'FLOOR -3 •� R W�FVN' �.: Y'.' , ,., a . • , 'FLOOR y , ,, i 4 FLOOR rr i 5 FLOOR ; N 6 FLOOR r* 7 FLOOR 8 FLOOR i, -- .. . Installing Company Name:I�Z 4 Check One Only, Certificate # SaN tr . Address bio S . n //VS ,Corporation City/Town�0,(abI..� State:® s, 71 a Partnership i Business Tel• Y71-Itd- —I 0 r Fax: Firm/Company I Name of Licensed Plumber/Gas Fitterl MC INSURANCE COVERAGE.` I have a current; ial 6iliN insurance policy or its substaMrai a{{quivalentrcwmeets the requirements of MGL. Ch 142 '�A If have fps, indicate i you ;checked Please the y type of coverage by chcking the appropriate box below. A liability insurance policy 17 Other type of:indem641 I Bond Q }y � •-' _ p f �hJ sti�:a r� 31«k„£ .� ,.,. t :'- : t. . � - 't OWNERS INSURANCE WAIVER: I am aware that the licensee does not have,ttie Insurance covera9e re quined by Chapter 142 of the Massachusetts General Laws, and that my signature on thisipermit application waties this requirement. _ 1 ,. Check One Only i Owner 0 Agent E I Signature of Owner or Owner's Q.. w1.w..L1__ wV ._ _ . L_ 48 • - o --- -- --..111_1__, --- --.F .._. _.. ,1111.,, ..o.o..o a........v....auv.....a.a auemnupu wi a umtwr regaramre vu g [ms appncaaon am ana ' accurate to the best of my Knowledge and that all plumbing work and Installedoii6 p'erknned under the permit Issued for this appik atlon ,will be In compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter,142 of the General Laws. �.. Type of License: , By Plumber v #... ritiel Gas Fitter ig ature of Licensedlumber/ Fitter i Masser { � ;• C4rN ;,ri r. Journsyeran License Number/0077 APPROVED OFFICE USE ONL LP Installer. , ,; M N 7 Date .... ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING, This certifies that . . ............ ....................... has permission to perform ........ W.!!� .... .. ......................... wiringin the building of ............. . .. ........ ......................................................... at .......1-1--. ....... I .............................................. North Andover, Mass. Fee.:-3�'. ............ Lic. No..// ....... 7.. PLECiRIC NSP ........ Check # 7753 .1e �-� Commonwealth of Massachusetts Department of Fire Services PemiitNo. Occupancy and Fee Checked �y BOARD OF FIRE PREVENTION REGULATIONS Rev. 9/051 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perfornied in accordance with the Massachusetts Electrical Gude (MEP. 527 MR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date • % (j .2 �IG 7 City or Town of: ItIo. 4 y,%/2 To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perforin the electrical work described below. Location (Street & Number) k $'(e f4 Lf S7 -- Owner J -Owner or Tenant �� nz_6i V qCi r= te Telephone No. 4171%(01,99Y Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building by—W Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of dieters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: w ` � z/ 7V /- A C.y eyz ivy Completion orthe following table may be ►vaived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers MIA No. of Luminaire Outlets No. of Hot Tubs Generators VA No. of Luminaires Above In - Swimming Pool rnd. jzrnd. El No. o mergency ig i irg 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 IH,-atpum No. of Alerting Devices _ T , No. of Waste Disposers p Totals: Number Tons KW No. of Self -Contained Detection/Alerting Devices --+ No. of Dishwashers S ace/Area Heating KW P b Local ❑ Municipal Q Other Connection No. of Dryers ry Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water Heaters KW 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 E uivalent 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 proofof same to the permit issuing office. . CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) General Liability 12/31/07 I certify, tinder thepains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Boissonneault Electric Corp. LIC. NO.: 11823A Licensee: /�u/t'�/►���Jn_ 3 Na�'!��•/% Signature _-----LIC: NO.: 2 key v (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.•( 978),454-0383 Address: 19 Chuck Drive, Unit #6, Dracut, MA 01826 Alt.Tel.No.• 978)458-9977 *Security System Contractor License required for this work, if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $�D Signature Telephone No.