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HomeMy WebLinkAboutMiscellaneous - 96 BRIDLE PATH 4/30/2018 (2)s OR Chi N I Kb ot�J 0" CC!. fD b cD n N cp ~c" p n. y 5 o �y k ` C,B by w o ti riq 1� DOC G' yO .�, tiO .�• CD •�• ^ O .p O w C w a 0� l l p N' r M�•O C rt 'COD O O O O c, n• ?" .�. o p O 5'S��c!o�amC, a �• i{ N y' �•C C N cp C OR y rt pCD N H O y O O to c w ao ti w po o'm w d C. o o p . o cn C O 'o NJ ,�'i• CD w, y O M o CD CD CP 7 N w `ri C1 'C O �C CD C W O`O'W'Q p cpD p CD C ca�Q,o °n w�o Wya o '00 C"w oc cm N �aWy o �' A'pi P.cb 5' o w C N d C CD CD y' p R. Cl y Q Np O b o a W y co rn ory o w 0p m • p Cc, o. C. C.•'O'ry o C 'o rt c. •4 Oq O O CD ��'• G y C y G�•� d mb b O SCD CD 'w"'. C 7 C. b cD by J� �y >] rn °' mo o p C AO C). C N a° w w O a° CDc o CD ,rt 4 CD y o rn trJ w CD o c o a o CDDN. N _ b 0,�'i O• N O0 N CSD "J ni (.' . ni Kn R, C b 0 t3Nip o p b W CD w � <a SNcrW C r 00 �+ co a C" CD Date.. F....... y..-.//.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that..r /.$ /G f l Ll" ..................................7...�......... ................ has permission to perform /"-' ............. ....e" ................. .......f .......... wiring in the building of ........ ....:r........... 4.. 5 ............................................... �6 /3.'- //'0! �. r at........................................... ........... �.......fl..:... ,North AndoYe►, M � Fee .. ."....... Lic. No %r%....... .................. IV-., ....... A.Ix`spe'c OR Check # �23Z, k 10558 ( rMmonwaa%O�ka.4lacA,6effs 2eparhnent of —ccim Semice9 BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. /Z) Occupancy and Fee Checked [Rev. 1/07] 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 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: l Z — 2 e—,"!l City or Town of: 41, AAA2!� X 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) 96, ao,)16 A -r14 Owner or Tenant Al in41tVA Telephone No. Owner's Address _tea na Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. /Z/10090 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: 1176r,41.1 7 nx, c` T,�A.✓5f-� :� r rGH Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: �, (>t�� . (When required by municipal policy.) Work to Start: IZ,12q, 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 covers a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCEOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information n this applicmjon is true and complete. FIRM NAME:, ZI L., ` / LIC. NO.:,�1 167-1- Licensee: i>DT.28�� Signature f/ ,.�� LIC. NO.:E.- (Ifapplicable, enter "exempt" in the lic nse number line.) Bus. Tel. No / Address: / a j l �/ �y'�— Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security workrequires 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. Owner/Agent Signature Telephone No. PERMIT FEE: S , f e% v ir« uuvrvm euum mu oe waivea a me lns eetor o 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 7,0 No. of Luminaires Swimming Pool Above ❑In- ❑ o. o mergency ig ing rnd. rnd. Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS �NoofZones No. of Switches No. of Gas Burners No. of Detection and Devices No. of Ranges No. of Air Cond. TotaInitiatin Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons ...................... KW No. of Self -Contained Totals: Detection/AlertinE Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security —Systems-- No. of Water No.KW No. of No. of No. of Devices or E uivalent Signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: �, (>t�� . (When required by municipal policy.) Work to Start: IZ,12q, 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 covers a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCEOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information n this applicmjon is true and complete. FIRM NAME:, ZI L., ` / LIC. NO.:,�1 167-1- Licensee: i>DT.28�� Signature f/ ,.�� LIC. NO.:E.- (Ifapplicable, enter "exempt" in the lic nse number line.) Bus. Tel. No / Address: / a j l �/ �y'�— Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security workrequires 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. Owner/Agent Signature Telephone No. PERMIT FEE: S , f e% v The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address:fi j /i'.IA1A A'I City/State/Zip:i A 1�l i-4 c"a 1)�4 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).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 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 of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10,0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other .Ally appncant mat cnecKs box # 1 must also fill out the section below showing their workers' compensation policy information. t 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 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: 1 1 1 Policy # or Self -ins. Lic. Expiration Date: Job Site Address: \ , City/State/Zip: � , A,� � «, Cf 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. 4 l� I do hereby ce iij under the pains and penalties of perjury that the information provided above is true and correct. 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 Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: I m (n m i y r fly I 1 y r fly I 1 m�ymy�Q �m4p� y y� Z 1 z -n 2-n t" C Mr - 0 M z Z: ZM'm oma cn O OMM z 14V3 r M oo 0 O• M 0 —4 -n ) Mm r— c am M C0 m m C) ;o C-0 0 -' m .0 0 z C) tz m = m C O > co CO) • U4 m 05 Z m < m 0 > r- -<z 0 CA 0 m z z Z V) m --I. M co � Eftre ... z -n 2-n t" C Mr - 0 M m Xrn co rn 0 M ZM'm oma � O OMM m 14V3 r M oo 0 < m yZO M In C0 m c1n), m mCO) -i I .0 0 00 00 CO) Date ..��`3� ........... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that.. ..... `/,,,'� ....... has permission for gas installation . 114 in the buildings off' 4-S .......................... . �G..�!�� . Q��. ..... No �=Andoer, Mass. Fee.. W,.rq Lic. No..��Z�-" L. . GASINSPECTOR Check # /F/94/ 8037 MASSACHUSETTS UNDDRM APPUCATON FOR PERMIT TO DO GAS FPITMG (Type or print) Date NORTH ANDOVER, MASSACHUSETTS , Building Locations .., / Owner's Name NewRenovation F1 Replacement El Permit # Amount $ zj&- 4- LL - Plans Submitted ❑ \j (Print o�ty.%�)i'�-�J��C///�/��-�7`l" Name Name of Licensed Plumber or Gas Fitter :�, L��C /_,%�•��j Chew 'One: Certificate Installing Company orp Partner. FlFirm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes �/ No If you have checked yes, please ndicat the type coverage by checking the appropriate box. Liability insurance policy [M . Other type of indemnity 13 Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the fMass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent 0 I hereby certify that all of the details and mron-nanon 1 nave Suoituucu Zvi GIILGIGU) iii aUU— aFF11 a 1— Q— — "l— --- w uic best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in rmmntinnre with all nertinent Drovisions of the Massachusos St -dip Aide and Chapter�4�f the General Laws. Y APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber9 Gas Fitter License Number er Master Journeyman w w o° H x x 0 w d H >1 z ] z p z N o x \ Gaw aw z H , zw44 H \ WWx x � 0 0 a H O SUB-BASEM ENT BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR ' STH. FLOOR (Print o�ty.%�)i'�-�J��C///�/��-�7`l" Name Name of Licensed Plumber or Gas Fitter :�, L��C /_,%�•��j Chew 'One: Certificate Installing Company orp Partner. FlFirm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes �/ No If you have checked yes, please ndicat the type coverage by checking the appropriate box. Liability insurance policy [M . Other type of indemnity 13 Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the fMass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent 0 I hereby certify that all of the details and mron-nanon 1 nave Suoituucu Zvi GIILGIGU) iii aUU— aFF11 a 1— Q— — "l— --- w uic best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in rmmntinnre with all nertinent Drovisions of the Massachusos St -dip Aide and Chapter�4�f the General Laws. Y APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber9 Gas Fitter License Number er Master Journeyman Date ..../. --� .: J .:?.1 . . TOWN OF NORTH ANDOVER 7TVPERMIT FOR GAS INSTALLATION This certifies that . c`". `:"'':��:� .... � . /.. .....��... . has permission for gas installation.-...�;. •:_ 4-... . in the buildings of ... ...................... at ...... North Andover, Mass, Fe4z7-41�7.. Lic. No.. �.t . '......... . �,/` GAS INSk bR Check # '� -2,- 7 0 59 705; FIXTI IRFS LU LU MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING Y City/Town:-jVar2�k _—z4 �, �CMA. Date:_1/-. Q�_____ Permit# __-'7 N Building Location:��_S.¢�%c _tea/h Owners Name: _�CLio J__ga ______ Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ©Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTI IRFS LU LU Y N Z Q W 0 U) X 0 = m= (7 J U ~ lX III N O 2 W W Z I— 0z Q Z W to w m O G D W O Q F i- o W X LY > fA W Z U) O~ W to V W = a O 0 Q W = li W ~ > U W> WZ W Z W O J F H O Z -i O -J O LL O Luc W I— W W > f' Z O LL' M N Q Q m W Z Q W W Q> O q O y Z Z W Z Z W Q H 3 U O C u. 0 0 X Z J O IL ¢ W H>>> O SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR Vu FLOOR 4 FLOOR 5 TH FLOOR 6 TH FLOOR 7 1H FLOOR 8 FLOOR // ---- Check One Only Certificate # Installing Company Name: _�.c.�1��l��1��.—_—_—_ ❑ Corporation ___----------- Address: � a�f �',���jc City/Town:_��i_�.�__ State: - ©� ❑ Partnership —_____--_-___ Business Tel: paw _ Fax: —_—_— -------- —--- — irm/Company-------____-- Name of Licensed Plumber/Gas Fitter: �.I •„� a INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes E"ro❑ 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 ------------------------------------------ Owner ❑ Agent ❑ Signature of Owner or Owner's, By checking this box ❑; I hereby 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 De in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By --------------------------- ®'P(umber TitleE] Gas Fitter ------ ster City/Town [-]Journeyman APPROVED OFFICE USE ONLY 0 LP Installer of Licensed Plumber/Gas Fitter License Number: ?1-9 673' — ACORD,. CERTIFICATE OF LIABILITY INSURANCE °11/06/2004rn PRODUCER 978-686-0826 JOANNE K MILLS INS AGENCY 156 HAVERHILL ST METHUEN, MA 01844 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED JAMES QUINLAN 1 KIMBALL CIRCLE METHUEN, MA 01844 INSURER A: N&D GROUP MUTUAL INS CO POLICY EXPIRATIONLTIR DATE IMMIDD/YY INSURER B: INSURER C: GENERALUABILITY INSURER D: INSURER E: EACH OCCURRENCE $ 500,000 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR OD'L NSRd TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MMIDDNY] POLICY EXPIRATIONLTIR DATE IMMIDD/YY LIMITS GENERALUABILITY EACH OCCURRENCE $ 500,000 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE � OCCUR R0312112 10/09/2009 10/09/2010 ED $ 50,000 PRE=(Anyone MEDn) $ 5,000 PERSONAL &ADV INJURY $ GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000 17 POLICY PRO LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY $ (Per person) ALL OWNED AUTOS SCHEDULED AUTOS PHRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR CLAIMS MADE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY WC TOROR Y STATULIMITS I I E- OTRH- ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS JAMES DIOZI 486 OSGOOD ST N ANDOVER MA 01845 L91_1�L"a011w_1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE /ickv Molina ACORD 25 (2001/08) © ACORD CORPORATION 1988