HomeMy WebLinkAboutMiscellaneous - 91 FULLER ROAD 4/30/2018 (2)I
Date. Z2 ^ Z'--
NorcrM
� TOWN OF NORTH ANDOVER
A PERMIT FOR WIRING
This certifies that ..........5?`.7'",. �Z T !. ..................................
..............................
has permission to perform ......Sr A ...... Sf !S r �"� ........... .3'E w
wiring in/the building of ..... r;;F.0..5............................................................
at .....I ....L�..... /J� ............................... North Andover, Mass.
Fee..// O �b... Lic. No. 6l ��
ECTRICALINS PECT�O��
Check # _ S�4 _ � "'
Commonwealth of Massachusetts Official Use only
Permit No.
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] leave blank
APPLICATION FdR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed i1 accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Q s- /(, - o
City ��--
or Town of. �0." �� ,4, , do v e, l— To the Inspector of Wires:
By this application the undersigned gives n6tice of his or her intention to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant F/11
Owner's Address q1 G
Is this permit in conjunction with a
Purpose of Building
Existing Service 1-100 Amps
New Service Amps
Number of Feeders and Ampacity
Location and Nature of Proposed
Telephone No.
ing permit? Yes No ❑ (Check Appropriate Box)
Utility Authorization No.
Volts Overhead ❑ Undgrd [ No. of Meters
Volts Overhead ❑ Undgrd ❑ No. of Meters
zal Work: 10's VW Solar
No. of Recessed Fixtures
-- -..
o. of Ceil.-Susp. (Paddle) Fans
- ...c ..0 cua.- a rr.res.
No. of Total
Transformers KVA
No. of Lighting Outlets
IN o. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Swimming Pool Above ❑ In- ❑
rnd. rnd.
o. o mergency ig ing
Battery Units
No. of Receptacle Outlets
Tqo. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
o. of Gas Burners
o. of Detection an
Initiating Devices
No. of Ranges
o. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
eat Pump
Totals:
. umber
Tons
TRV --No.
of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
eating Appliances KW
SecuritySystems:
No. of Devices or Equivalent
No. of Water KWNo.
Heaters
of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. HydromRssage Bathtubs
No. of MotorsTotal I;P
elecommumcations Winng:
No. of Devices or E uivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurnice 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 J . BO ❑ OTHER ❑ (Specify:)
Estimated Value of Electrical Work:(Expiration Date)
3 (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the pains and penalties of perjury, that the information on this application is true and complete,
FIRM NAME:. ST 5 1 ec k c t ,, i, LIC. NO. A I Lf (,j, 7
Licensee: j,e S-cvta V -1 ,C, r) Signature LIC. NO.:V023.9
(If applicable, enter "exempt" in the license number line) Bus. Tel. No. -
Address: S 8 Inti cie.c%- Or- Tom, n C C l�nro o l8"7�i Alt. Tel. No.: q T -090f
OWNER'S
OWNER'S INSURANCE WAIVER: I am aware tt li t;ie 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. S
Signature Telephone No.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, Mass. 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual) : S /ec �IrCG. LVl
Address: S,F we'ried (ami v t
City/State/Zip: Tft. t 6d moo . k Phone#: S-7-7 — 6CS�
Are you an employer? Check the appropriate box:
1. �I am an employer with --A
4. El 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.
employees and have workers'
[No workers' comp. insurance
comp. insurance. $
required]
5.0 We are a corporation and its
3. ❑ 1 am a homeowner doing all work
officers have exercised their
myself [No workers' comp.
right of exemption perm MGL
insurance required] t
c. 152, § 1(4), and we have no
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 41 must also fill out the section below showing their workers' compensation policy information.
tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contactors that check this box must attach 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. / /j
Insurance Company Name: ` I I -e *cl C I G
Policy # or Self -ins. Lie. #: Expiration Date: QZyZ -201
Job Site Address: / r✓Ile r- (��f City/State/Zip: IVOrA Ve GAJ %L: Old
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 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certiN under the pains and penalties of perjury that the information provided above is true and correct.
Date:
Print Name: >,U "I ,� Phone #: R 7 i <- 6 c S- - q �2 (d ()
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 Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact person: Phone #:
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91 Fuller Road
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MA 01748
North Andover, MA 01845
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Ellis Residence`
114 South Street
91 Fuller Road
Hopkinton, MA 01748
North Andover, MA 01845
Monday, April 09, 2012
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Date.. 0 5 .....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .... .......
has permission to perform .... ...................
wiring in the building of ...................... ..........................................
at ........... 11 .... ....... '�. h ........................ . North Andover, Mass.
Fee ..Lic. Nol.75�� ................... .... . ......
7�/q EL I RICAL INSPECTOR
Check #
8461
l,ommonwea& of /rlaMachueetb 9� �'O�fficial Use Only
--
2eparlment of gire Servicee Permit No. U
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEJ), 527 CMR 12.00
(PLEASE PRIG ' OR )PEAL INFORMATION) Date: ( �
City r Town f: (�r n �iV tX To the Inspect r o f sires:
By this applicat dersignekives notice of his or her intention to perform the electrical work described below.
Location (Street & ber)
Owner or Tenant Mt-
Owner's
Y
Owner's Address
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service Amps
New Service Amps
Number of Feeders and Ampacity
Telephone Nog7S-73y-ol j
Yes ❑ No ❑✓ (Check Appropriate Box)
Utility Authorization No.
Volts Overhead ❑ Undgrd ❑
Volts Overhead ❑ Undgrd ❑
Location and Nature of Proposed Electrical Work:
No. of Meters
No. of Meters
Completion of the follotivinQ table mal) be ivaived hi, the Inspector of ll ices.
No. of Recessed Luminaires
No. of Ceil: (Paddle) Fans
Total
TransSusp.
Trsformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- El
rnd. rnd.
o. o Lighting
Batter), Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. I Detection and
Initiatin 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 KW
Loc onnection er
No. of Dryers
Heating Appliances K
KW
Security Systems:
No. of Devices or E uivale
No. of Water
Heaters KW
No. of No. of
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail ifdesir•ed, or as required b>> the Inspector of Wires.
Estimated Value of Electrical Work: J�S,�. (�(� (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 cove age is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE M BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains at;d penalties of perjury, that the information on this application is true and complete. l'l q3 {
FIRM NAME: j�(n /CS �Qly►r? �j�e1 j(i LIC. NO.: 7 4 4 C
Licensee: _,hn Signature�fr LIC. NO.:s'sc14�
(/f applicable, en "ex n pt" in th icense weber 1! j. m In O{� r� Bus. Tel. No.:�
Address: _ 7 Qo / Alt. Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security work requires Depa ent of ublic Safety "S" License: Lic. No. v t l 4 r'
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 /y1
Signature Telephone No. PERMIT FEE: $ I.CJ
N2
Date ..X: .I � - - -!� - -
TOWN OF NORTH ANDOVER
0
PERMIT FOR PLUMBING
This certifies that ... / tf ...... . ......................
has permission to perform F -.........................
plumbing in the buildings of .... � :'..1. �. z ......................
at ... q/. .......... North Andover, Mass.
Fee.. Lie. No.. . ...... ...... �-- ............
PLUMBING INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
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MASSACHUSETTS UNIFORM APPLICATION PLUMBING
FOR PERMIT TO DO PLUM
(Print or Type)
Date S- / i i9 -�DrJd Permit # 4W /)
Building Location Rr,`
Owner's Name_
6
1 b V1y o 5 Type of Occupancy I /i:
y
New E]Renovation L-1C,eplacement ❑ Plans Submitted: Yes ❑ No ❑
mowa
SEWER#
FIXTURES
SEPTIC#
Installing Company Name The Plumbing Co., Inc
Address P 0 Box 1607
Wakefield Ma 01880
Business Telephone 781-246-0019
Name of Licensed Plumber
Clifford H Giles
FINSURANCE COVERAGE:
e a current liability Insurance policy or hs substantial equivalent which meets the requirements of MGL Ch. 142.
Yes CD( No ❑
have checked ye;, please indicate the type coverage by checking the appropriate box.
A Ilablifty, Insurance policy EJX 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 Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of (honer or Owner's Agent Owner ❑ Agent ❑
I 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 all plumbing work and installations performed under the permit issued for this application will be in compliance with all
Pertinent provisions of the Massachusetts State Plumbing Code and tiapter 142 of the Ge oral Laws.
eY V-en4s�e�—d�l
TIUe Signaturember
Cit IT Type of License: Master E� Journeyman [�
nr'1'FiOwn(OFFICE SSE ONLY) License Number 8707
Check one:
LX Corporation
❑ Partnership
❑ hrm/Co.
Certificate #
7279C
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TOWN OF NORTt� ANDOVER
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Div. Public Works
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary .
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: Et - L i O v% M 19 N b C L.L Phone G g9 _2 t o
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Subdivision
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Street 91 Fy 1_1, E2 ROAD St. Number 91
************************Official Use Only************************
' RREECOMMENDATIONS OF TOWN GENTS•
Date Approved '&2119,2
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Comments
Date Approved
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Septic Inspector -Health
Date Approved
Date Rejected j
Date Approved
Date Rejected
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