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HomeMy WebLinkAboutMiscellaneous - 90 MIDDLESEX STREET 4/30/2018N J O CiD C) v m CO m X SOO 1 m m 9045 Date/`.�+. r NOR7M TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �SsACHUSE`t ✓r This certifies that..../ ............ has permission to perform . ..:.................... plumbing in the buildings of .�.i.Seoz... 4 ........... at . 940 ./??/d4t'.'............ North Andover, Mass. Fee-:52....Lic. No... 6.4� ........................ Check # 5q- / / PLUMBING INSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING W. C it Town: ti "w�tJ' MA. Date: �' Permit# Location: I' hSr�uNam': Owners e f Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential [❑i / _ New: U Alteration: [T Renovation: FIXTURES Plans Submitted: Yes n No DEDICATED Addres • S /�i N 5 ❑Corporation �:�� City/Town: P4� \ t�State. -7� _ ❑ Partnership Business Tel:/ o %` 3 y17 Fax: i` ❑ F' /Company Plumber: Name of Licensed Plumb INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes o ❑ If you have checked Yes, please indicate the .type of coverage by checking the appropriate box below. A liability insurance policy -E] 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 ❑ Agent ❑ 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 permi s ed for this application ill be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Cha er 42 o enerai Laws. i By Type of License: 1 Title ❑ Plumber ign ture of Licensed Plum or- City/Town ❑ Master 1 APPROVED (OFFICE USE ONLY) ❑Journeyman License Number: IZ FWD„ z Z >U SYSTEMS En N d C Z Z I-- Y Q U H W a G C a ONO H W CQ' FW- N W a V~I Y LA O Z d N N W !- W LL a 3 W C Q tY Z d' 0 W O H D C' W Z N W Z U d LL W U = cn C Q in O ~ = z > LL O 0 N a J Z Q Z 2 V1 W H W F- W 4'S O I W LU a m m i; o LL= ,� g g ) Ln Ln3 a a a a 3 F- 0 Q a< Q i' F- N 3 SUB BSMT. BASEMENT 1sT FLOOR 2ND FLOOR / 3RD FLOOR 4T" FLOOR 5T" FLOOR 6T" FLOOR 7T" FLOOR 87' FLOOR Installing Company Name: �� a } Check One Only Certificate # Addres • S /�i N 5 ❑Corporation �:�� City/Town: P4� \ t�State. -7� _ ❑ Partnership Business Tel:/ o %` 3 y17 Fax: i` ❑ F' /Company Plumber: Name of Licensed Plumb INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes o ❑ If you have checked Yes, please indicate the .type of coverage by checking the appropriate box below. A liability insurance policy -E] 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 ❑ Agent ❑ 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 permi s ed for this application ill be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Cha er 42 o enerai Laws. i By Type of License: 1 Title ❑ Plumber ign ture of Licensed Plum or- City/Town ❑ Master 1 APPROVED (OFFICE USE ONLY) ❑Journeyman License Number: IZ 10188 Date........7"'..1.. ..� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that......v.✓`.L.. . ............/1�Y.....�.1'T ........ has permission to perform ............ �-.............................................. wiring in the building of ................ L#..�?l............. ........................... at �� �:. ............. orth Andover, Mass. Fee ©.. �.... Lic. No.1.79FIrl................................ ..... .. ........ . EL ICAL I pECTOR Check It `7193 17819421983 OSHEA ENERGY 6orwra0nwea& 0/�cr77r/asoac�uaeEfl oUeparfoteni o�.,�•ir® �grviCae BOARD OF FIRE PREVENTION REGULATIONS Of ircial Use Only Permit No. /U f F Occupancy and Fee Checked (Rev. 1/07) leave blank PAGE 01 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the lvlassachusem Electrical Code (MEC), 527 CUR 12.00 (PLEA SE,P)UNT flV INK OR TYPE ALL I.NFORMATXO/V) Date: 7,/91—// City or 'down of /%o a_7w AlyoyA. To the Inspeclor of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 591t.0p cC--S'C-X S T Owner or Tenant ,jRe �•�'�d M Telephone No. Owner's Address S-04In6 Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead] Undgrd ❑ No. of Meters New ervice Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Nulntiber of Feeders and Ampacity Location and Nature of rroposed Electrical Work: �! Completion o rhe ollowin table may`be Ivaived'bthe I>tis'' ector'o ; 63rires. No. of Recessed Luminaires 2 No. of Ceil.-Susp. (Paddle) Fans' 'a o. o Tota Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA . No..of Luminaires Swimmin Pool Above In- o: o inergency tg mg g rnd. ' grad. Barter 'Units No. of lteeeptacle Outlets No. of Oil 13uraers k'IRE ALARMS No. of Zones No. of switches �? No. of Gas Burners o. of ]Detection acid Initiating Devices No. of Ranges No. of Air Coad. otal g No of Alerting Devi Tons ces No. of Waste Disposers eat I'uixip umber _ons KW� o. o elf -Contained Totals: - Detection/A)ertin Devices No- of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers heating Appliances KW ecunty stems.ft. No. of Water No, of llevices or E' iiivaleat Hearers KW No oSigns Ballasts Data Wiring: No. of -Devices oe Equivalent No. Hydromassage Bathtubs No. of Motors Total RP Telecommunications Wiringg: No. of Devices r E uiv19 nt OTHER: Alloch additional detail ifdesired, or. as required by the inspector of Wires. Estimated Value of Electrical Work: 41_400t (When required by municipal policy.) Work to Start: 'j r/,� t!� Inspections to be requested in accordance with MEC Rule 10, and upon completion. • INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless - the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equiVale.nt. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE (li BOND 0 OT14ER ❑ (Specify:) I certify, under the pains and penaltieXsv-zovq perjury, that the information on this applica ion is !rue and complete. FIRM NAME: ' 6 Cis LIC. NO.: Licensee: /l� `�(� (� _ Signature LIC. NO.: (!f applicable,ertt "exam in the license number h e.) Rus. Tel. No. Address G ' X . ©//VG �� Alt. Tel- No.: *Per M.G.L. 6.147, s, 57-61, security work requites Department ff Public 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) ❑ owner ❑ owner's agent Owner/Agent Signature Telephone No. PER11�tT FEE.' $ paulx� IO/Z (&C4 die, �o„24—I1 fe o Address: P© BOX a0 City/State/Zip: D W U, M A. 018 �o % Phone #: G Are you an employer? Check the appropriate box: . ® 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. ❑ 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t listed on th h d h t C attac e s ee . These sub -contractors have employees and have workers' comp. insurance.* 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' COMM insurance required.] 0 71,7301 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. + 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Fg:ea_ie�ss — Policy # or Self -ins. Lic. #: WC 9(c?7 9"? i Expiration Date: ZB "oZ0 f a Job Site kddress: go Mz V& rxEx 09 yC City/State/Zip: NoreTN A/VDOVEIt 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 8250.00 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. 0 62, Xuzo Date: 7-/ 2 —// / r% ?f'R _36 // Phone I W If IF • Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/L,icense # LBoard Athority (circle one): Health 2. Building Department3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector rson: Phone #:' The Commonwealth of Massachusetts Department of .Industrial Accidents Office of Investigations ;" >1 600 Washington Street z ! Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _Applicant Information Please Print L.epibly 0 a� Name (Business/Organization/Individual): — Address: P© BOX a0 City/State/Zip: D W U, M A. 018 �o % Phone #: G Are you an employer? Check the appropriate box: . ® 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. ❑ 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t listed on th h d h t C attac e s ee . These sub -contractors have employees and have workers' comp. insurance.* 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' COMM insurance required.] 0 71,7301 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. + 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Fg:ea_ie�ss — Policy # or Self -ins. Lic. #: WC 9(c?7 9"? i Expiration Date: ZB "oZ0 f a Job Site kddress: go Mz V& rxEx 09 yC City/State/Zip: NoreTN A/VDOVEIt 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 8250.00 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. 0 62, Xuzo Date: 7-/ 2 —// / r% ?f'R _36 // Phone I W If IF • Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/L,icense # LBoard Athority (circle one): Health 2. Building Department3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector rson: Phone #:'