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HomeMy WebLinkAboutMiscellaneous - 92 MILLPOND 4/30/2018t Date ........... .....�...... ..................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that Kft...�...1.!................................................................:...... has permission for gas installa ion ............ ..!g: R-. ................................ in the buildings of ......... t'.2.........ti5 r)......................................................................... at ................................................ .. i' �11� - ,................:... . North Andover, Mass. .......... ...... aD Fee...- '"'.... Lic. No...) 35 ,3. ....... ........................................................... GAS INSPECTOR Check # Z 9521 I� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITYd r� MA DATE 9 PERMIT # JOBSITE ADDRESS 9Z A. 1�/� D OWNER'S NAMEG OWNER ADDRESS TE3OS� FAX TYPE OR TYPE OCCU;7RENOVATION:E] COMMERCIAL ��{ EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: REPLACEMENT: El PLANS SUBMITTED: YES El NO _ APPLIANCES 7 FLOORS— BSM' 1 2 3 4 5 6 7 S 9 10 11 1 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER �. _.,..�_ I-- - -- �- _ PIPMD! ocG i i_ _ i I`_ _ i. III I IIIII i I i I FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER— ROOFTOP EATERROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE ve a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES I _ NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY [j BOND E] 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: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT 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 pr ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. AA�� PLUMBER-GASFITTER NAME LICENSE # rrr 11 SIGNATURE MP_ MGF 0 JP 0 JGF LPGI © CORPORATION e� PARTNERSHIP ®#= LLC Ej#f COMPANY NAME: __, Gd -&__ _ A ADDRESSf CITY STATE�ZIP TEL FAX - 1 CELL EMAIL pal P O O 0 Z O El LOP) CL U w Cl) oLLJ LLI cn z rA Fr a (L < U) LLI I-- U- C 0 The Commonwealth of Massachusetts Department of lndustvigl AccMiks Office ofluvesiigations 600 Washington Street Boston, MA 02111 -www.mass gov1dia Workers, Compensation Xnsurance Affidavit: Builders/Contract Name Addre� City/State/Zip: �� �e— /�Pholle Are yo n employer? Check the appropriate box: 1.1 am a employer with,_ 4. ❑ I am a general contractor and I employees (full and/or part-time).* have lifted the sub -contractors listed on the attached sheet. T These sub -contractors 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' comp. insurance required.] 2. ❑ 1 am a sole proprietor or Partner- ship artnership and`haveno.employees working forme is any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself [No workers' comp. insuranceregaired.] i Type of project (required): 6. ❑ Now construction f 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.[] Plumbing repairs or additions 12.❑ Roofrepairs 13.1] Other ,!Any applicant that checks box#f must also fill out the section below showingtheir Workers' compensation policy intormatlon. N'Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an gdditional 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 joie site information. Insurance Company N Policy ## or Self' ins. Lic. #: &,ioce C3 Expiration Date: l S Job Site Address; `Ol ,� �N� 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 requiredunder Section 25A of MOL 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 maybe forwarded to the Office of Investigations ofthe DIA for insurance coverage verification. I do hereby cert under the pains and penalties ofperjury that the information provided above is true and correct. Phone ##• ',12 r of 1 '7_,�' Official use only. Do not write in this area, to he completed by city or town official. City or Town: 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 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 ofhiw,• express or implied, oral or written." An employee is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a j oint enterprise, and including the legal representatives of aAeceased employer, or the redeiver or tnistee ofan individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house havingnotmore than three apartments and who xesides therein, or the occupant ofthe dwelling house of another who employs persons to do mAtenance, construction orrepair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be, deemed to be an employes." 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 p erformance 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), addresses) andphonenumber(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees oilier than the members or partners, are not required to carry workers' compensation insurance. if an LLC or LLP does have employees, apolicy is required. Be advised thatthis affidavit maybe submitted to the Department of industrial Accidents •fox 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 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 whichwill be used as a reference number. in addition, an applicant ihatmust submitmultiple pexmit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnocess ary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A� copy of the affidavit that has b ccn officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit -ii on file for future permits or licenses. Anew affidavit must be filled out each year. Where a .home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e. a dog license orpermit to burn 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 faxnumber: Tho CQm. mollwealtbLof Massa.,rhu�otE DT.afaent d1ndust dal .Accidonta O:floe Q:ffAveSiigatjoxt, 6bG Washh pa greet Boston, UA 0.21 11 T01 # 617-7.2-' -4.900 oxt 406 or 1-877-MASSAF`F, Revised 5 26-05 Fax # 617-727-7749 _WWW-Maw,govaa • r rp 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 ofhiw,• express or implied, oral or written." An employee is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a j oint enterprise, and including the legal representatives of aAeceased employer, or the redeiver or tnistee ofan individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house havingnotmore than three apartments and who xesides therein, or the occupant ofthe dwelling house of another who employs persons to do mAtenance, construction orrepair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be, deemed to be an employes." 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 p erformance 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), addresses) andphonenumber(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees oilier than the members or partners, are not required to carry workers' compensation insurance. if an LLC or LLP does have employees, apolicy is required. Be advised thatthis affidavit maybe submitted to the Department of industrial Accidents •fox 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 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 whichwill be used as a reference number. in addition, an applicant ihatmust submitmultiple pexmit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnocess ary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A� copy of the affidavit that has b ccn officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit -ii on file for future permits or licenses. Anew affidavit must be filled out each year. Where a .home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e. a dog license orpermit to burn 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 faxnumber: Tho CQm. mollwealtbLof Massa.,rhu�otE DT.afaent d1ndust dal .Accidonta O:floe Q:ffAveSiigatjoxt, 6bG Washh pa greet Boston, UA 0.21 11 T01 # 617-7.2-' -4.900 oxt 406 or 1-877-MASSAF`F, Revised 5 26-05 Fax # 617-727-7749 _WWW-Maw,govaa Aa0 of Wakefield BOARD aE B PLUMBERS ANDG4SF TTERS , ISSUES THE F0LLOWI NG L1 CENSE .• yh L I CEAtb AS A MASTER f?.LUMBER .. j MAR.kf B MAGN I F I CO I. Donohoe i & Gas Inspector y 31 FOREST STREET �, �W Tel: (781) 246-6388 Fax:(781)224-5020 MI D:DLETON MA 01949-201 IJ - -- -- 135505/0,1!16 204667 .:,• .;e! sC'�AM11A(1BIWCAI TIJ Ac \AA L' A4:.tl t I VV^�r�w '1 270 Date.'.l... 'k0RTsq TOWN OF NORTH ANDOVER to 41 PERMIT FOR MECHANICAL INSTALLATION This certifies that has permission for mechanical installation ........................ in the buildings of .... P:�, v2II-}.r` 45 .......................... at ...... P<r............ North Andover, Mass. Fee. Lic. ......... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Commonwealth of Massachusetts Sheet Metal Permit Date : > Estimated Job Cost Plans Submitted: YES NO Business License # Business Information: Name: Street:_ S J City/Town: Permit # -.,9- / Permit Fee: $ r7�z Plans Reviewed: YES NO Applicant License # ( 3 9_ (( Property Owner / Job Location Information: Name: AA & YR- Pc'y V_�M S . Street: City/Town: O Telephone: (- In T-- fs 3 6- 2 l 3 Telephone: Photo I.D. required / Copy of Photo I.D. attached: YES V NO Building Type: 7Uv�.v��s`f'� Residential: 1-2 family _/ Multi -family Condo / Townhouses Commercial: Office Retail Industrial Educational Institutional Building Cubic Footage: under 35,000 cu. ft. over 35,000 cu. ft. / Sheet metal work to be completed: New Work: Renovation: S�Jc� Q •'/ HVAC Metal Roofing Kitchen -Exhaust System Chimney / Vents Provide brief description of work to be done: aw INSURANCE COVERAGE: I have a current liabili insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes [E No ❑ If you have checked Yes, indicate a 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 112 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent 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 sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Date Date By Title City/Town Permit # Fee $ Inspector Signature of Permit Approval Progress Inspections Comments Final Inspection 7master of License: ❑ Master -Restricted ❑Journeyperson ❑Journeyperson-Restricted F07 Comments Signature of Licensee License Number: /? Check at www.mass.gov/dpi .t . d6 Sheet Metal Commercial Guidelines / Life Safety / Critical Systems Inspection Checklist Yes leo N/A., Set of stamped engineering documents and detailed description of mechanical system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper joumeyperson-to-apprentice ratios Fire dampers with access door properly installed and checked for operation Smoke and combination fire / smoke dampers with access doors properly installed - actuator checked for proper operation (May also be verified by fire department during fire alarm testing) Duct smoke detectors with access doors properly located (May also be verified by fire department during fire alarm testing) Smoke / atrium exhaust systems installed and operation verified (May also be verified by fixe department during fire alarm testing) Stair pressurization systems installed (where required) and operation verified (May also be verified by fire department during fire alarm testing) Grease / kitchen hood exhaust system installed with all seams and connections welded airtight with properly located cleanouts. Proper cle`ances, fire rated enclosures and pressure testing required. Seiorai res .Taints installed ��rliO:w ,.quired 'oin equipment and d�t.tv. ;, v Duct penetrations in fire'ratQ--ivali:, and flQ' drs sealed Metal roofing systems installed watertight using proper materials and fasteners Flexible duct nuns installed 6'-0" maximum length Ductwork installed using proper hanger spacing, hanger stock, threaded rod and angle iron Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining Volume dampers installed for each supply air branch duct New/clean - properly sized filters installed (final inspection) Testing and Balancing report complete (final sign -off) Sheet Metal Residential Guidelines / Inspection Checklist Yes No N/A Detailed description and sketch of sheet metal system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper joumeyperson-to- apprentice ratios Equipment sized per heating / cooling load calculations Duct work sized per manual "D" calculations Bath/ shower rooms contain mechanical exhaust fan vented outdoors Electric dryer exhaust properly installed maximum total run 35'-0", maximum flexible run 8'-0" Flexible duct runs installed 14'-0" maximum length Volume dampers installed for each supply air branch duct Ductwork installed using proper gauges and hangers Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining New/clean - properly sized filter installed (final inspection) Testing and Balancing report complete (final sign -off) .5-7_ Commonwealth of Massachusetts City of Haverhill Everett Mitchell or Sub P(urnbing/Gas Inspector a. City Hall 4 Summer Street, Rm 210 Tel: 978-374-2.341 Haverhill, MA 01830 Fax: 978-374.2337 Office Hours: Mon& Fri Only 8-9am&3-4 pm 2 r n 1 8 5.-8_ TOWN of MANCHESTER -BY -THE -SEA ;q 7s ? n Joseph P. Guzzo 5,> Plumbing and Gas Fitting Inspector * 1645 Office hours: Tues. & Thurs. 6:30-7:30am Town Hall • 10 Central Street Manchester -by -the -Sea, MA 01944-1399 Tel.: (978) 526-2000 Fax: (978) 526-2001 Town of Topsfield Topsfield, Massachusetts _z Stanley Kulacz Plum o bing & Gas Inspector Town Hall Phone 978-887-15 8 West coirimonStreet 1449 Fax 978-887-1_ Topsfield, MA 0 Town of Reading a 16 Lowell Street Reading, Massachusetts 01867 Tel. 781.942.6615 Fax 781.942.9( PETER SPARCO Plumbing & Gas Inspector Office Hours: Monday — Thursday 7:00 to 8:00 AM ,o Town of Rockport Plumbing & Gas Inspector t Joseph Guzzo Office Hours — Mon. Wim{. Fri. 6:30 am to 7.30 am 978-546-3701 Date .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that /'.� ...................`.�.'....�.................�...-..�..0 .�......�.............V.....!.�.. has permission to perform ... ....."r....,rL`..... r....�`"� wiring in the building of...._'�Z.� ................................................................................... at........................................................... orth Andover, Mass. Fee......: ^il� ... Lic. No..�.!..:..1:.41.................................................. ELECTRI CALINSPECTOR I Check #� Z- 1273? M1 d�A ConzownweaA o f Mamac" .may cc�7 cc77� oDeparbnant ol..tire S'WiM6 BOARD OF EIRE PREVENTION REGULATIONS Official Use Only Permit No. V2-r-1 and Fee Checked rRev• 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massacbusetts Electrical Code (MEC), 527 CMR 12.00 / (PLEASE PRINT IN INK OR TYPE ALL INFO)MM77019 Dater <_4 1 City or Town of: D6 rC6V& n 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) ` Owner *or Tenant Telephone No. Owner's Address 1_41114 Is this permit in conjunction with a building permit? dies ❑ No M t0mck Appropriate Box) Purpose of BuildingUtility 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: ��` �� ) OL_16_w_ !',,tlhv fnllnwina tnhlo may he waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No, of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool d. ❑grud. ❑ o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners oechon an . oteInitiatin Devices No. of Ranges Nu of Air Cond. Tons eat PumlP umber Tons ot Space/Area Heating KW Heating Appliances KN No. of o. o Signs Ballasts No. of Motors Total HI �E- �r ��-­ T-;- t" �/✓)'� No. of Waste Disposers No. of Dishwashers No. of Dryers No. of Water Heaters KW No. Hydromassage Bathtubs OTHER: Attach additional Estimated Value of Electrical Work: , :?�_ (When required 1 Work to StartKA Inspections to be requested in accordane INSURANCE COVERAGE: Unless waived by the owner, no permit for. the licensee provides proof of liability insurartcta including "completed Opel undersigned certifies that such coverage is in force, and has exhibited prool CHECK ONE: INSURANCE 0 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and Akuldes of perjury, that the information of FIRM NAME: Licensee: No Qfapplicable, en!_- Address: 290 Broadway suite 117 Methuen ma 01844 *Per M G L c 147 s. 57-61, security work requires Department of Public Safety "S" License: 77 Alt L11C.NV3:oJva _ .IC. NO.: 4 94e Tel.No.• QTS 6R7 0544 Tel. No.: Lic. 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 a ent. Owner/Agent PERMIT FEE: $ Signature - TeIephone No. r 1�4 CommenweaA of Vamac"ib Ciefrartment o�.fire seradeed BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/071 (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 j (PLEASE PRINT IN INK OR TYPE ALL INFO 77019 Date:�q �P,Y AM 7 City or Town of: k�nr:'T-9 n ()61161Z To the Inspector of Wires: By this application the undersigned g ves notice of his or her intention to perform the electrical work described below. Location (Street & Number)_ Owner 'or Tenant Owner's Address Is this permit in conjunction with a build'mg permit? Yes ❑ No Z3 (Check Appropriate Box) Purpose of Building 1 & Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Vohs Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 6!�—, % e&. -/L2 r4� rr r !•.......1-f...« ..ffGa fi.Iy—;— mAla miry ho wnrvad by lite Insvector of wires. Telephone No. No. of Recessed Luminaires .,......�._- - -•-- ----- - No. of Ceil.-Susp. (Paddle) Fans ---.o. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires AboveIn- Swimming Pool P-rnd. grad. o. o mergency Lighting BajtM Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners i o.o Detection an Initiating Devices No. of Ranges No of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers . �Totaall : amber Tons Detection/Alerting Devices e cSelf-Conin D __ ___ ' No. of Dishwashers Space/Area Heating KW Local [I Municipal Other Connection E] No. of Dryers Heating Appliances KW security Systems:, No. of Devices or Equivalent No. o Water KW Heaters No. of o. of Si ns Ballasts Data Wiring: I No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Wirrn TelecommunicationsNo. of Devices or E uivalent OTHER: Alracn aaaamnat aciatt y utu1"4 , yr &" 7"$- y ...� ...g .. . J •• .• Estimated Value of Electrical Wozk: , -�/ e (When required by municipal policy.) Work to Start Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVE GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of hability 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 [I OTHER El (Specify:) I certify, under the pains and hies of perjury, that the information on this application is true and complete. FIRMNAME: Aries Electrical Service a _ Cnn.trols LIC.NO15550a Licensee: Norland Michaud Signatur- _ AC. NO.:3�4 —94e (If applicable, enter "exempt" in the license member line.) Bus. Tel. No.: qT R h R 7 0 544 Address: 290 Broadway suite 117 Methuen ma 01844 Alt. Tel. No.: *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 required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Ogent PERMIT` FEE. a Signaturgnatur e � Telephone No. The Commonwealth ofXassachusdts Dghw*n&d of lndustrfal Accidents Office t fIrmestigationS 6811 washiitgton Street Boston, lMlasm 02111 www.n&U&gov/dia Workers' Compensation Insuranee Affidavit: BuildersfContmetorw%lectricianslPlumbers Applicant Informatics Please Print Legibly Names Ar RIESLRCTRICAL SERVICE AND CONTROLS LLC Address: -290 BROADWAY STITTR 117 CitylStatel7ap: =j�pt-}tnpn �a n� Baa i�haHel�:- 9?R �8� o�aa Are you an employer? Check the appy box: 1. I am an employer with_ - 4 ❑ I am a gmerai contactor and 1 employees (full and/or parttune}* - have hired the sob -co vs 2 -z i am a sole proprietor or partner- listed on the attached sheet oWp w4 have no eh• rleyees These yrs have vvoricing%r lite in any capacat)►- employees and have workers' [Nowor we comp. wwronce, camp- i . required] 5.13 Weare a corporation and its 3.0 1 am ahomeawnerdoing allwoik of mrshweetc msedtheir myself -[No workers' comp right ofonperm MGL ir�surarttae t - a I57, f 1(4.t and we have no emphya- [no wailme comp. insuraocerequired.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8- ❑ Demolition 9. ❑ Buildingaddition - 100- %Fectrical repairs or additions XX 11. ❑-Plumbing repairs or additions 12.11 Roofh epairs 13. ❑ Other TnUIUM nerswwsaa��a hh aomg�woifca�theAbheoatsideaontracboesamstsdm&anew affdavitbaMadag=dL tCDRt84PXV#WcbKktbTsb= EatrBdtss aTaet thesameefffiesuboaot orsamtstatewhgtberormtSmcnMiesbaveempioyces if ibesnb-costraclossLaveempioseea,tLef==zM gft_didrworherBeommmumvamber. I Mn an emplgYrthatisPnvvubrighrar_-4M'CVAV9MaffiM hUWUnMjbrjV eVloyees Below is theporwy mldjobaite information Insurance Company Name:. Policy # or Self -mss. Lim ly/ �/.�� C3 �7 '/4t Expiration Date Job Site Address- �a.�/Jl �! Chy zip:�� Attach a copy of tiie workers' cempeasiation policy declaration page (shaving the policy -number and expiration (dale). Failure to secure covgtage as required under Section 25a of MGL 152 can lead to the im position of criminal penalties of a fine UP to $1,500.00 andlor orie year imprisormteut as well as civil penalties in the farm of a STOP WORK ORDER and a fine of $250.00 a day against violator. Biadvised that a copy oftbi&stdtement maybe forwarded to the Office. of Investigations of the DIA for coverage verification. I do herby cerdfy under thepaim andpe wW= ofpgrJury that#he informs &nprovided above is true and correct Prim Name:. Normand Michaud Phone#: 978 687 0544 Ofchd use only Do not write in this area to be completed by cft or town of ficial City or Town- Permit #: Issuing Authority (circle one): I.BmM of Heath 2. Bk9WWg Beparaueut & CSty/rewn Clerk 4. Metrical Inspector S. Plumbing Inspector 6. Other Contact person: Phone#: 0 44. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING Lr -- (Print or Type) IW hIO.ANDOVER , MA Mass. Date "r 3 19, 4z Permit Building Location 7� MILLPOND Owner's Name NO.ANDOVER,MA Type of Occupancy " RES New ® Renovation ❑ Replacement ❑ , Plans Submitted: Yes❑ ' No C7 Installing Company Name CALLAHAN AIR CONDITIONING Check one: Certmcate u Address 91 BELMONT STREET Ccrporatlon NO . ANDOVER , MA . 01845 ❑ Partnership Business Telephone 508-689-9233 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter JOSEPH KEVIN CALLAHAN INSURANCE COVERAGE: I have a current Ilablifty Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142- Yes 42Yes R] No ❑ It you have checked�Les, please Indicate the type coverage by checking the appropriate box. A Ilabfltty Insurance policy Zl Other type of Indemnity ❑ Band O 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 cn this permit application waives this requirement. Check one: owner -0 Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) In ove appficatlon are true and accurate to the best of my knowledge and that all plumbing work and Inslallatlons performed under the permit Lisued for this appflcaU will b In pflance with all perUnent provisions of the Massachusetts State Gas Code and Chapter 142 of the neral law By TyDe of Ucense: Plumber Lj c 6 nse um a or Gas titer Title filter Ot", ter Ucense Number M-3440 City/Town neyman MFI-K-A-..D (CFFIC 0 . N N cc W &n N Y U G VI rn W W x O U © F- n J N W l - < m w Fu u O a c a LU w < = Z H N O W V F Uj W O` ►- J W 2 �n O L7 y_ _ 7 3: p O J U C i O 0. �! O SUB—BSMT. BASEMENT 1STFLOOR 2ND FLOOR ORD FLOOR I_ 4TH FLOOR STH FLOOR 6TH FLOOR i 9 7TH FLOOR I 1 BTH FLOOR 1 Installing Company Name CALLAHAN AIR CONDITIONING Check one: Certmcate u Address 91 BELMONT STREET Ccrporatlon NO . ANDOVER , MA . 01845 ❑ Partnership Business Telephone 508-689-9233 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter JOSEPH KEVIN CALLAHAN INSURANCE COVERAGE: I have a current Ilablifty Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142- Yes 42Yes R] No ❑ It you have checked�Les, please Indicate the type coverage by checking the appropriate box. A Ilabfltty Insurance policy Zl Other type of Indemnity ❑ Band O 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 cn this permit application waives this requirement. Check one: owner -0 Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) In ove appficatlon are true and accurate to the best of my knowledge and that all plumbing work and Inslallatlons performed under the permit Lisued for this appflcaU will b In pflance with all perUnent provisions of the Massachusetts State Gas Code and Chapter 142 of the neral law By TyDe of Ucense: Plumber Lj c 6 nse um a or Gas titer Title filter Ot", ter Ucense Number M-3440 City/Town neyman MFI-K-A-..D (CFFIC 0 . JW C7- 7# rr!s 2 p cL Date .. !.: / .9:-? ....... 8 NORTH TOWN OF NORTH ANDOVERQL p PERMIT FOR GAS INSTALLATION NUSESS`' ... SAC This certifies that has permission for gas installation ... :,1.'i :,r .............. in the buildings of .-i X/.? ........ ......... at .. `i �? ..�"�? .�' .f . ��.? . � ............ North Andover, Mass. Fee—)?..... Lic. No.3 M :... .......................... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File