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Miscellaneous - 96 CHESTNUT STREET 4/30/2018 (2)
N lr� Date.....73.l..'.. ....... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION '"This certifies that.�,,)(/.4**��&o.61 ....... 4 . ...... sa—W�5 ............................ ........ .. has permission for gas installation . in the buildings of .................................... at................. ........ Fee�.P, Lic. No./ � Check # ,/e)? 9396 .................................................................... ... North Andover, Mass. GAINSP . E . C�(OR ............................. ` •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY C� U� '—i�-. MA DATE PERMIT # JOBSITE ADDRESS , OWNER'S NAME GOWNER ADDRESS R TE ______=FAX TYPE OR OCCUPANCY PE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:E] REPLACEMENT: El PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER. BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER _ I FIREPLACE i9 s /= ✓L� .�- IJ .. I _ l _:_--� FRYOLATOR IV4v ✓t ✓1 J _ E —_ 1 ( _.. _ __ _ .—� __ FURNACE GENERATOR G3-0305':- 30 -J ... J. . GRILLE INFRARED HEATER --- LABORATORY COCKS_— MAKEUP AIR UNIT __ I OVEN ---L --- POOL HEATER ROOM/ SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER I UNVENTED ROOM HEATER) I, WATER HEATER -. _ . -- OTHER -- - - - - - --- - f INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAG Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE 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 [I AGENT SIGNATURE OF OWNER OR AGENT 1 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 witb all ertin rovisi n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. o PLUM BER-GASFITTER NAME -._ r ,1 LICENSE # �� 7 ( �. SIGNATURE �'?P 2/MIGF El JP JGF Q LPGI © CORPORATION ©# [= PARTNERSHIP 0#= LLC D#= �1PANY NAME: ADDRESS I, STATE�ZIP (J TEL �J' CELL _- _ EMAIL O z 0 H U W a w a� o Z � O yrl W } � W O w O F 93- Wu =con ~' r LU 4 Q a CO LLI O > w � LLI o a a a 0 J F °- a Q co ui s w F— LL co F °z 0 H U 000a O The Commonwealth of Massachusetts - Department ofIndustrigl Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/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 (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. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a 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 of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. El 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. i Homeowners who submit this affidavit indicating they ai-e doing all work and then.hire outside contractors must submit anew affidavit indicating such. tContractors that checkthis 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 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 cert& under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: Phone #: 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 Informati®n 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 ofhire,- express or implied, oral or written." An employer1 s 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 dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or 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 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 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 certificate(s) 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 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 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 (ifnecessary) 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 o permit not related to any business or commercial venture (i.e. a dog license or permit 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 fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigajtions 600 Washington Street Boston, MA 02111 Tel, # 61.7-727-4900 ext 406 or 1:-8777MASSAFE Revised 5-26-05 Fax 4 617-727-7749 wwwanass,govaa JUL-02-2014 13:10 THE ANGUS GROUP 603 421 0062 P.001i001 cQRO CERTIFICATE OF LIABILITY INSURANCE DAT E(MMIDD/YYY1� 07/02/2014 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(los) must be endorsed. It SUBROGATION IS WAIVED, Subject to the terms and Conditions of the policy, certain policies may require an endorsement. A Statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s), "An, Ir•ee INURED THE ANGUS GROUP INSURANCE AGENCY 116 ROCKINGHAM ROAD LONDONDERRY, NH 03053 WILLIAM DESANTIS DBA DES ENTERPRISES P.O. BOX 1 PELHAM, NH 03076 COVERAGES r:Fl?TICIr`_ATC arllallneb. :FF YOUNG 603-421-0021 MMG INSURANCE COMPANY NAIC a THIS IS TO CERTIFY THAT THE POLICIES OP"INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT, 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID. CLAIMS.. , LTR TYPE OF INSURANCE ADONSRLPUCYNUMBER MM OD/YVW% LIMITS OBNGRALIA�ILT A SC.013065503131/201403131/2015EAcrloccuRRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMI p 3 100,000 CLAIMS -MADE OCCUR MEO EXP (Any one peraon) S 15,200 PERSONAL & ADV INJURY S 11000,000 OENERALAGGREGATG 3 2,000,000 GEN1 AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AOO S 2 OOO OOO POLICY PR LOC $ AUTOMOBILE LIAMILITY COMBINED SINGLE LIMIT ANY AUTO .(Ea &cadent) $ BODILY INJURY (Per persgn) $ ALL OWNED AUTOS BODILY INJURY (Per aooldenl) 3 SCHEDULEDAUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON -OWNED AUTOS $ � UMSRBLLAUP62OCOUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE _ AGGREGATE $ DEDUCTIBLE RETENTION 3 $ WORKERS COMPENSATION - H- AND EMPLOYERS, LraluTY Y N — OFFICERlMEMBERUCLUOEp7ECUTIVE ❑ N/A E.L. EACH ACCIDENT $ (Mandatory In NH) If yee deeenbe under E.L. DISEASE. EAEMpLOYEE S D6 Ae,' TI N OF OPGRATIONS below F,L, DISEASE - POLICY LIMIT I; ' DRSCRIPTION OF OPRRATION31 LOCATIONS / V✓ HICLC$ (AtUch ACORD 101. Additional Remark& Schedule. N more apeoe is naulrnd) RESIDENTIAL PLUMBING CONTRACTOR FAXED TO: 978-688-9542 TOWN OF NORTH ANDOVER MASSACHUSETTS, 01845 ACORD 25 (2009/09) The ACORD name and loco SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 111E EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED R FFRE3 E N TATI VIa of I rights reserved. TOTAL P.001 IVY 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the l permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time o£ongoing construction activity, and may be -deemed. by.the-Inspector_of _Wires abandoned.and.invaliddf he—.. _ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this puipose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending"through August 15, 2012. 8 — Permit/Date Closed: ❑ Permit Extension Act — Permit/Date Closed: * * * Note: Reapply for new IN Date ..... 3...-1..2-........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING /9 6. / This certifies that .......................... ................................................................... has permission to perform ..... ............ wiring in the building of ....... E '. ............................................................ at ............. ............. �..........��......................... , orth Andover, Mass. Fee ... �........... ic. No.... .....................fiRICA��SF��i ...ELE` Check # 35'a 8726 10775 o Official Use Only �Zl A5 Con:monivealtli of )11aJ1acLJetb ^-� c'� Permit No. / h-- 2l eparfinenf of _� ire Service9 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]i07] (lease blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the \Massachusetts Electrical Code (i`•IEC). 5"'7 CN -IR 13.00 (PL EA SE PRINTI.VIVK RT//��PE -ILL 1ATORiLITIOA9 Date: 0 q � /.0"j � z- City•or Toi Vyff®,/i'Il do yeirl{ To the Inspector of Wires.- By ires.By this application the undersigned gives.ptice 4f his or j er inteption to perform the electrical -work described below. Location (Street & Nu ber) Owner or Tenant S f p IIV 1 Al Owner's Address 7 6 6+ $ 7-ylyir 3 Is this permit iri conjunction with a building permit? Purpose of Building Existing Service ' Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Telephone 'C( 5� ?17--5- 6 ' e d oA,,4�6 Yes ❑ No (Check Approo1aXiIJo'Z5 Utility. Authorization No. Overhead ❑ Undgrd ❑ No. of deters Overhead ❑ Undgrd ❑ No. of Meters' 12 �- Completion of the following table may be ,valved bt• the Insnecror of No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA J No. of Luminaire Outlets No. of Hot Tubs —J Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ g �I t o. of mergency tg stung ,— 1 Md. grnd. 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 --1 No. of Alerting Devices No. of Waste Disposers Heat Pum Number Tons KW ............... No. of Self- on.tained (! Totals Detection/Alerting Devices No. of Dishwashers Space/A'rea Heatinb KW.. Local ❑ Municipal. ❑ Otiuer Connection No. of Dryers Heating AppliancesKIYV Security Stems:" No. of Devices or Equivalent No. of Water KW No. of No. of _ Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of MotorsTotal. HP Telecommunications Wiring: No. of De` ices or Equivalent _ OTHER: !tach additional detail if desired, or as required by the Ir Spector tf fi ires. Estimated Value of Elec ical Work: XJ L� (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. CHECKONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) Self Insured I certify, under the pains and penalties of perjury, that the 'SOrmation on this application is true mid complete. FIRM NAME: ADT Security Services LIC. NO.: C -i``J Licensee: Mark A. Brophy Signatue LIC. NO.: C-45 -(Ifapplicable, etuer `'exempt " in the license iramber line.) Bus. Tel. No..603-594-5928 Address: 18 Clinton Drive Hollis, NH Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. 00953 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. PEKVIIT FEE: S "( l� .�� _ctA=REGISTERED SYSTEM CON.TRACTOP_.', ., .. ,_ ,•.. - 7. ISSUES THEABOVELICENSE TO: SECURIT-Y, SERVI^CES, - 1*ARK; A .BROPHY-..,SR .f< Y. AVE - •b:UNI VERSIT - ST.W110D Mk. 02.09-0-21.1.,'';.:-.. r.. C' 07/31/13 :849174::::. fold. TTun oclaen Al-g.AA PV-'OmdOn DPS-CA1 Co 35M-lelo9-tot62009UCENSEFORk41 Keep top for receipt and change of address notification. DIG SAFE CALL CENTER: (888) 344-7233 j'. ✓1g •£n»ro�u�yxu�cait�, cf',./�a.t�acf� DEPARTMENT OF PUBLIC SAFETY v, -4 rl S- License Number:' SS CO 000953 Tr. no: 195.0 Expires: 02/07/2013 S -License: ADT MARK A BROPHY SR 410 UNIVERSITY AVE WESTWOOD, MA 02090 Commissioner Keep top for receipt and change of address notification. DIG SAFE CALL CENTER: (888) 344-7233 j'. 9'175 Date-A/w/...�f.//. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .. /V .. Z'11 -A Q ......................... r. has permission to perform .. ......... . plumbing in the buildin s of ...por < ... o/� ........... at ....9C-ekIP7. _�'. ............ . North Andover, Mass. Fee. Y700. Lie. No./ZJrS G• �' ice' `� ...... s PLUMBING INSPECTOR Check # 6 Ll -SUB BSMT. BASEMENT �sT F OOL R 2ND FLOOR 3RD FLOOR 4T" F OOL R ST" FLOOR IT" FLOOR 'T'FLOOR iT" -FLOOR MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town:_ %V�a�-�,�/�/���rd MA. Date: Permit# Building Location:—7(.,, Gl i/�s� S`� Owners Name: Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: N,/ Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ Installing Col,;p�;nylv"am,: (� �,� j - Address: -33 C City/Town: State:�� Business Tel• -� Fax: Name of licensed Plumber: INSURANCE r' wmt Ar,. Chsck 0neOsi1,. f. . ta�.s-;iYoC;'iE t�- ❑ Corporation ❑ Pa nership Firm/Company 1 have a current liabilitzinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 Yes No ❑ If you have checked Yes, please indi a 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 Si nature of Owner or Owner's Agent Owner ElAgent ❑ I hereby certify that all of the details and information i have submitted (or entered) regarding this application are true ar!d fo Knowledge and that all p!!�mh!ng work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision o th assachusetis State Plumbing Code and Chapter 742 0` enerai Laws: acculian to the best of troy 3y Type of License: 'itie K;h�laster er Si re f Li nsed' lu , er :!ty/Town PPROVED (OFFICE USE ONLY) ❑•Journeyman License Number: FIXTURES Ix DEDICATED H z SYSTEMS Z Z UO 2fZ z a Z }- Y 'a N N v U EN. W j in 0 C O to N W W c' L f_ _z N C } H _Z a a N Y aLn `S a h N vai W ,-'y a_ H N O W [K p N Z to 0 u a X ¢ E a F a zO~H=d a. j v 0z OQ y am 'n 'a- 3 o u a a d a C7 0 C9 9 Installing Col,;p�;nylv"am,: (� �,� j - Address: -33 C City/Town: State:�� Business Tel• -� Fax: Name of licensed Plumber: INSURANCE r' wmt Ar,. Chsck 0neOsi1,. f. . ta�.s-;iYoC;'iE t�- ❑ Corporation ❑ Pa nership Firm/Company 1 have a current liabilitzinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 Yes No ❑ If you have checked Yes, please indi a 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 Si nature of Owner or Owner's Agent Owner ElAgent ❑ I hereby certify that all of the details and information i have submitted (or entered) regarding this application are true ar!d fo Knowledge and that all p!!�mh!ng work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision o th assachusetis State Plumbing Code and Chapter 742 0` enerai Laws: acculian to the best of troy 3y Type of License: 'itie K;h�laster er Si re f Li nsed' lu , er :!ty/Town PPROVED (OFFICE USE ONLY) ❑•Journeyman License Number: ,,r The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA. 02111 SY www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/ContractorsAElectricians/Plumbers MliCant Tnfnrma+:n„ Name (Business/Organization/Individual): Address: -City/State/Zip::�,r��% j(f j�3�j phone #: ------------------"�-- Are y n employer? Chec appropriate box: 1. I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part -tune).* 2. ❑ I am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheget. 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.] ;. ❑ I am a homeowner doing ,officers have exercised their 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 re ired G.- 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 ,I- ] 13-ElotherI *Any applicant that checks box #1 must also fdl 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 information. insurance for my employees Below is thepolicy and job site 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. t do Izereby certyy y�der the pains that the information provided above is trye and correct. wrcrar use only. Do not write in this area, to be completed by city or town official. City or Town: PermitucenSe Issuing Authority (circle one): I. 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 j oint 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 dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or 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 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 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 -contractors) name(s), address(es) and phone number(s) along with their certificate(s) 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 thatthis 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 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/liceuse 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 (ifnecessary) and under "Job Site Address" the applicant should write "all locations n (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 Commomwealti, of i1assa:.chiisetts Department of Industrial Accidents Office of Investigations 640 Washington Street Boston? 1!A 42111 Tel. 4 61.7.727-4900 ext 406 or 1-877- MA SSAFB Revised 5-26-05 FaX # 617-,727-7749 www.mass.l;ov/dia DateVQ. ...... r--5,saoTOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that.. / t�G�..1,44.q.............. has permission for gas installation . A.k4) ker*4, !mak /, in the build*n s)ff .,57ev4, 17(?),h ................. at ...9G .......................... NorthAndove Mass. 4W 14 Lic. No. ..... Fee.. GAS INSPECTOR Check# 0 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: A!/f%d��/dEJr�� , MA. Date: Per mit# Building Location: �� C.r�-5��"— Owners Name: Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential ❑� New: [E" Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES IY co X ui Z wa co v = co X co to O 0 W o ~ 0 o W 01Z Z W W Z co co V Z LI cn (7 o w p ~ w ILL w= X U W Z (7 J Iw- I— O Z J (� LL Z w W W UZ W} Q �' W W m> O Z O N F- Z H x o LL t7 C) x x O a0 _F >>> p SUB BSMT. BASEMENT 1 FLOOR NFLOOR Installing Company Name: Check P �/�1 (y/mss �� Check One Only Certificate # ❑ Corporation Address:City/Town: State: El Partnership Business Telccmi3� %Zfc� � Fax: _ _ irm/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No ❑ If you have checked Yes, please md' a the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ndemnity ❑ 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 ❑ 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 Perim t pr6ision of the Massachusetts State Plumbing Code a hapter 142 of the General Laws. By Type of License: ❑ PI r Title ❑ as Fitter Sig ure L' ensed mb /Gas Fitter Master City/Town Journeyman APPROVED OFFICE USE ONLY ❑ LP Installer License Number: %2 j 5 / The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigationg 600 Washington Street Boston, MA 02111 yi www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers mlicant Inforrnafinn Name Address: '-4 C-' /A City/State/Zip:,'. y r r/ i`. _i phone Are an employer? Check the appropriate box: 1 • L1 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 shget. t ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp, insurance workers' comp, insurance. 5. ❑ We aie a corporation and its required.] ;. E] I am a homeowner doing .officers have exercised their all work myself. [No workers' comp. - right of exemption per MGL c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp, insurance re ired i G� Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. [] Building addition 10. ❑ Electrical repairs or additions I1.❑ Plumbing repairs or additions 12.0 Roof repairs qu 13.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation polrcy information. I 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. lam an employer that is providing workers' compensation insurance for• my employees Below is the policy anti job site information. Insurance Company Name Policy # or Self -ins. Lic. #: 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 civilpenalties 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. Ido hereby pains that the information provided above is true and correct. 9JJJiciai 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): I. Board of Health 2. Building Department 3. City/Town Clerk 6 Other 4. Electrical Inspector 5. Plumbing Inspector 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 dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or 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 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 performance ofpublic 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), address(es) and phone number(s) along with their certificates) of insurance. Limited Liatility 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 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 ifyou 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 Iicense 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 (ifnecessary) 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 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 fax number: `xhe Com,.:monweaRth- ofi Massac'ausetts Department of Zndustriai Accidents Ofce of Investigations 600 Wash!Von Street Boston; MA, 02111 TO. # 617-727,4900 ext 4406 ox 1-877-MASSME Revised 5-26-05 Fax # 617.727-774.9 'c ww.mass.govldia. Date.......� �_ r q ./ .. ......... ................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... T�.�...... �� LC ............................. has permission to perform....A� .... T 8' z ............................................... ...... ...... U wiring in the building of...............................-�. 5................................... at� !t!r!��^, Mass. Fee .. .. � ��....."^ Lic. No.. ..l.�a Sy ..J,AAndover ELEOR Check # . t 0 . 10470 Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. l o --(,) o 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 (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 11:51111 City or Town of. NORTH ANDOVER 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) 9t. Cf4CSTN -rr Owner or Tenant 91 A471#1 Telephone No. moi' 7 V —Y ')9--/ 2u2 Owner's Address 57A^+F' AT gfjoyF Is this permit in conjunction with a building permit? Yes ©-**�— No ❑ (Check Appropriate Box) Purpose of Building A001T: •al Utility Authorization No. Existing Service 2-0.0 Amps 12-10 / 2Y -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: 17vkt> S1p r Ore9o? #4 ppr7,ra, j A-rl Act�ly� Zo C0177oletion of the 010winv InhlP n mt he wnivod by tho Ine—mr nfWiroe No. of Recessed Luminaires Z t, No. of Ceil.-Susp. (Paddle) FansNo. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above In- rnd. El 1n- ❑ o. o mergency ig mg Battery Units No. of Receptacle Outlets `j S No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches 16 No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number I Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water Kms, Heaters No. of No. of Signs Ballasts Data Wiring: I No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent 3 OTHER: fi Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: bl� ap4P (When required by municipal policy.) Work to Start: j l /1- 1 N 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 liabiliinsurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov age is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) ]certify, under the'�� �airs anti peva f perjury, that the i niation on this application is true and complete. FIRM NAME: 1 1 �4 j` U LIC. NO.: � Licensee: �g 5 j �'1 1� Signatur LIC. NO.: (Ifopplicable, e er "exe/� t" in the license n, 7ber line.) Bus. Tel. No.: Address: ItV LS Vli1 \`tl Wr 3e-7 Alt. Tel. No.: (1_ *Per M.G.L c. 147, s. 57-61, security work requires Department of 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 aent. Owner/Agent Signature Telephone No. PERMIT FEE: $ &-U-ex- 'r� 12- lo-zl;7 ' The Commonwealth of Massachusetts Department oflnd'ustrial Accidents Office of Investigations 600 Washington Street _ Boston, MA 021XX Sv www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AADJJMnt Information Name (Business/Organization/Individual): —��,, gF� TNT E l EC7rz4c ,5,9Udr,&- Address: 2-2. vl u�►�c,� 1'L,� City/State/Zip: s;, t LaV , nJ4./ d3g-?-3 Phone #:_ 9 -7 9- q7*- y91 / Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 2.Kemployees (full and/or part-time).* have hired the sub -contractors I am a sole proprietor or partner- listed on the attached shget. I hip and have no employees These sub -contractors have working for mein any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3111 am a homeowner doing .officers have exercised their all work Myself [No workers' comp. right of exemption per MGL c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp, insurance re uired ] • Type of project (required): 6. 0 New construction 7. ❑ Rem.odeling 8. ❑ Demolition 9. [❑ Building addition 10. ❑ Electrical repairs or additions 11. El Plumbing repairs or additions 12.0 Roofrepairs q 13.[] Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I 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. Xam an employer thatispro viding workerscompensation insuranceformy employees Below is tltepolicy and job site information. Iusurance 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 ofMGL 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. Ido hereby certif under the afns andpenalties ofperjury that the information provided above is true and correct. - 77 /;� A_ Official use only. City or Town: t•(76.—y-9 t Do not write in this area, to be completed by city or town official. Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 6. Other 4. Electrical Inspector S. Plumbing Inspector 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, or written." express or implied, oral 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 apartinents and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or 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 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 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 -contractors) name(s), addresses) and phone number(s) along with their certificate(s) 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 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 which will be used as a reference number. In addition, an applicant that must submit multiple permit/liceuse applications in any given year, need only submit one affidavit indicating current Policy information (ifnecessary) 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 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 fax number: The Gommonweal'i - oji lvjl cxtt�setts Depattmelat of h dusWal Accidents Office of Investigations 600 Washington stmet B oston; MA. 0211 X Tol. # 617-727-4900 ext 4406 or 1-877-M4SSAa Revised 5-26-05 Fax #.6X7"727^774. www.mass,govjdia 1 ff 1181 Elm Street, Suite 205 Manchester, New Hampshire 03101 GDS Associates. Inc. Ena nnts and Darsnl;ants Duct Leakage Test Results Phone: 603.656.0336 Fax 603.656.0301 Builder Name:-lltr t'Y/12OL� S. (Name on Building Permit) Property Address: (- L --H1 771�u7- ' LURK "O✓S7k. (city/town), NI _(state) Duct leakage testing protocol: (check one): Results 1. Post -Construction Dud Leakage to Outside Test: ❑ CFM25 2. Post -Construction Total Dud Leakage Test: E9, 9V CFM2s 3. Rough -/n Total Leakage Test with Air Handler Installed: ❑ CFM2S 4. Rough -in Total Leakage Test without Air Handler Installed; ❑ CFM25 Note: CFM25 = Cubic feet per minute at 25 Pascals of test pressure Duct System 1: DDI Ol) Test Fan Mounted to: IAir Handler ❑-Return Plenum -❑-A Return Register in: (room) Test Pressure Tap was located: -Test Hole in Supply Plenum ❑-A Supply Register in: (room) Dud System 2: TestFan Mounted to: ❑-Air Handler ❑-Retum Plenum -A Return a t (room) Test Pressure Tap was located: ❑-Test Hole in Supply Plenum El -A Supply Register in: (room) In order to verify compliance with the Section 403.2.2 of International Energy Conservation Code (IECC 2009) and Section M1601.4.1 of the International Residential Code (IRC 2009) a home of this size of tg3a square feet (conditioned floor area) must have duct leakage no greater than: System 1 System 2 1. Post -Construction Duct Leakage to Outside Test: M2s (8% of conditioned floor area) 2. Post -Construction Total Dud Leakage Test: TCFCFM25 (12% of conditioned floor area) 3. Rough -in Total Leakage Test with Air Handler Installed: CFM25 (6% of conditioned floor area) 4. Rough -in -Total LeakageTest withoutAirHandler installed: CFM25 (06' of conditioned floor area) Therefore, this home: Meets the duct leakage requirement within Section 403.2.2 of the IECC 2009 ❑ Does Not Meet the duct leakage requirement within Section 403.2.2 of the IECC 2009 Corrections Needed at: (printed) Date: GDS Associates -Home Energy Ratings of N WEngland Is a RESNET-accredited Home Energy Rating Provider and is a registered EPA ENERGY STAR Partner , It Date ...... �. ........ 2 ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......................... TY ...................... has permission to perform ................ wiring in the building of ............. .................................... at ............ ?1-6.................... ,North Andover, Mass. Fee-�/r ..... Lic. No. Alf.6 ................ ELrECTRICAL INSPECTOR Check # --, 9097 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 9®g � 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 (PLEASE PRINT OR TYPE ALL INFORMATION) Date: (� City o Tow of: WtsA Arickvtr To the Inspe for of Wires: By this application ndersigned_gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) U,'le, j z: i , Owner or Tenant 5' (Vi,n -i �&Q,LA Q Anb'AS _ Telephone N Owner's Address 5Qn'),C U U Is this permit in conjunction with a building permit? Yes ❑ No X BLDG PERMIT # Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters r Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Install low voltage security system at above location Completion of the following table may be 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 Swimming Pool Above ❑In- Elo. rnd. rnd. o Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS JNo. of Zones No. of Switches No. of Gas Burners No, of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pum Num.bcr ....................................................... Tons KW No. of Self-Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal Other No. of Dryers Heating Appliances g pp Kms' urity Systems:* No. of Devices or Equivalent 1 No. of Water KW No. of No. of in ; Heaters Signs Ballasts No. o eve 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: (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. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: Broadview Security LIC. NO.: 749C Licensee: John Holmes Signature r�� f'k�(,�� LIC. NO.: SSCO 001163 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 978-657-0443 Address: 155 West Street, Suite 6 Wilmington, MA 01887 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. Owner/Agent Signature Telephone No. PERMIT FEE: $� 'M Location � A- TOWN OF NORTH ANDOVER Check # 00" a. z? '1655) ---��- / Building Inspector o •. Certificate of Occupancy $ ��s''"•''t�' swcwusE Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ 40-0 ve-, TOTAL $ /6-r' w Check # 00" a. z? '1655) ---��- / Building Inspector i% 'D A TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, REN OVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING mss*?:. s,, sb'Q W �fiBIiC: ,p 'f f BUILDING PERMIT NUMBER: ��DATE ISSUED: SIGNATURE: ✓/vG l Building Commissioner/I for(f Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: (p Gi�ESTNVT S� 1.2 Assessors Map and Parcel Number: 6e) jA 1� Map Number Parcel Number 1.3 Zoning Information: Zoning Dia6dt Proposed Use 1.4 Property Dimensions: Lot Area s Fronta e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R 'red Provided Required Provided 1 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record Z -7 `Q 0 01A�S Name (Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: o1ALIA T 1v1.Tf— LicensednnConstruction Supervisor: � � 011 4 G. G3 -1-T V IUB N & p 9 Acua— AM Address 2 eLV— 1776— ro 'Sd (^7 —i nature Telephone Not Applicable 0 License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone 00 M M ic z O O z M 90 O e r M �ppqq r r z ^ Q W-4 SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 Zi 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. —Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ElExisting Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: n /� o -ON i� l -A V cgF_ SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant flFFICiALtJSE (QNLY 1. Building $ n� ,cc/ K (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee tet x (b) /OD ,- 4 Mechanical HVAC 5 Fire Protection 6 Total_ 1+2+3+4+5 '. :1':i '3_ I Z Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT CONTRA TO APPLIES FOR BUILDING PERMIT AOR / Cl� 4- as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS I -MIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE i 2K1 (0 3 S��so�J o K^— 6,^-) FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that_ y ` 3 Boards and Departments having jurisdiction havebeen obtained. This does no from the applicant and/or landowner from compliance with any applicable or requirements. ve ******************APPLICANT FILLS OUT THIS SECTION APPL►CANT-126o.iW L�>1 HONE q78 6 6-0 7' % LOCATION: Assessor's Map Number `` L Ct-7$ q?rl 9196 I l PARCEL SUBDIVISION LOT (S) STREET ti �`ST. NUMBER **'*****OFFICIAL USE REC MMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISIrRATOR DATE APPROVED 7 DATE REJECTED COMMENTS TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED. DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm 19J93 17:16 FAX 978 837 3336 NORTHERN ASSU, 0001/001 IO/ o-"r,PGAGP I SPECTION PLAIT NORTHERN ASSOCIATES, INC. 401 SOUTH BROADWAY, LAWRENCE ISA. 01843--3522 TEL:(978) 837— 3335 FAK:(978) 837-3336 MORTGAGOR: 5TEVEN T KEYNOLD5 DEED R.EF: G972/34) LOCATION: 9G CNE5TNUT STREET PLAN Kff.- I G-27 CIYY,5TATE: N ANDOVER, MA SCALE: 1 "=60' DATE: 2115/03 JOB #: 20-11.01574 LOTS 5,G.7 59.100 S.F_ LOT 4 09 ; �` Sr lay x b, +1 N N m GaRa6E W0. STOI.O DF�Y c CI-1f5TNUT STRff ffT RTIFIED TO:. LAWRENCE 5AVING5 BANK od hazard zone has been determined by scale I d is not necessarily accurate.Until def Mtive plans z issvad by HUD anal/or a vertical control survey perfarrned,precise elevations cannot be determined. 130 North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a property licensed solid waste disposal facility as defined by MGL c 11, S 150k The debris will be disposed of in: > . MEL -1,0 `1 �-f�-nOKJ -- WA r -, X Pi 5 6 C `[6 uW (Location of Facility) Sig u of Permit Applicant ` 7-13 -o3 Date DOTE: Demolition permit from the Town of North Andover must be obtained for this project through.the Office of the Building Inspector NATIONAL GRANGE MUTUAL INSURED INSURANCE COMPANY 55 West Street, Keene, NH 03431 Telephone: 1-888-646-7736 CONTRACTORS POLICY DECLARATIONS Named Insured and Mailing Address RONALD HUNT 3 AUTUMN DR DRACUT, MA 01826 Agent: COSTELLO INS AGCY INC/RAIS AGENT PHONE : 978 374 6352 POLICYHOLDER INFORMATION Policy Number: MPS48273 Account Number: CACS48273 Producer Code: 20 0284 Named Insureds Business: CARPENTRY -RESIDENTIAL Entity: INDIVIDUAL Policy Term: 12 Effective: 11/24/02 (12:01 A.M. Standard Time at the address Expiration: 11/24/03 of the Named Insured stated above) In return for the payment of the premium and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. See the attached schedules for Description of Premises, Property Coverage, Optional Coverages, Forms and Endorsements applying to this policy and Mortgagee Schedule if applicable. BUSINESSOWNERS LIABILITY COVERAGE LIMITS OF INSURANCE Liability & Medical Expenses - each occurrence S 300,000 Personal and Advertising Injury Limit S 300,000 Products -Completed Operations Aggregate Limit S 600,000 General Aggregate Limit 600,000 Fire Legal Liability - any one fire or explosion S 500,000 Medical Expense Limit - per person S 10,000 Business Liability and Medical Expense: Except for Fire Legal Liability, each paid claim for the above cover- ages reduces the amount of insurance we provide during the applicable annual period. Please refer to section DA. of the Businessowners Liability Coverage Form. For policies subject to premium audit: Annual Audit Applies. Commercial Inland Marine Coverage Part S 250 Estimated Annual Premium: 5 649 TOTAL PREMIUM AND CHARGES S 899 Countersigned: 8 6 A- V—t-9_AsJ-i uk�, 64-5470(9100) 11/13/02 NEW BUSINESS TB i _- ✓/ae '�nitzmn�uc+eall�i o� i�j�ar�us BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 047574 ry� , Birthdate: 04/05/1963 Expires: 04/05/2004 Tr. no: 20347 Restricted: 1G RONALD J HUNT �. 3 AUTUMN RD C.t DRACUT, MA 01826 Administrator L I "ward of };gilding Itegutattons and Standards }COME IMPROVEMENT CONTRACTOR { Registration: 136156 i Expiration: 611912004 y Type: individual RONALD J. HUNT RONALD HUNT _ 3 AUTUMN RD. DRACUT, MA 01826 Administrator �F= xcVBcnm60 Varnion 4.12 Member Data Description: Ridge Beam Deck Connection: Nailed Live Load: 30 plf Dead Loaq: 15 plf DOL: 115% Nan -standard Loads Type (Description) ReolacerIntnt Uniform(plf) Bob la? Doylc 07/14/03 Revnolds Res 1,01 pm loft Member Type: Beam Application: Roof Lateral Bracing: Continuous Slope: .00 112 Moisture Condition: Dry Building Code: Other Deflection Criteria: U240 live, L/180 total Filename : 13047,14,03,2 Member Weight: 11.1 plf Trib. Live Dead Begin End Width start End Start End DOL d' .00" 18' ,00" 270. 80. 115% 1e0o f Bearings and Reactions Input Mlnlmum Worst Case Location TY0e Width Len th Total 115% 1006/a Dead Total 1 0' .00" Wall 3.50" 1.75" 2810# 2101# 0# 7099 2810# 2 15'6,75" Wall 3.50" 1,75' 2810# 21014 0# 7090 28100 Design spans 15'6,75" Product: 2.0 R gid.Lam LVL 1-3/4 x 11.875 2 Ply Allowable Stress Design Control: Positive Moment Ma114f*4turers Installation gulde MUST be oonsurt2d for multiply wnnectlon details and alternatives All praeum neme9 mm.. tnelerftFka of [noir ro pecrlN! awnam GpRY'Igh! (G)7619.2002 by Keymprk Fnterprlt", IME. ALL RIGHTS RESERVED. Mom T N—th... i Strutt fill WaM Pred UCle 1l79We1eO--ler•PMVklenee Trnpk Unit 1 sunon Ma 01590 Actual Allowable Capacity Location Loading Positive Moment 10932,'# 22891,'# 47% 7.78' Total load 1150A Shear 2452.# 9081.# 27% 14,78' TOW load 115% Max. Reaction 2810.0 9186.0 30% 0' bead load LL Deflection .364$" .7781" L/511 7.78' Total load 115% TL Deflection .4879" 1,0375" L/382 7.76' Total load 115% Control: Positive Moment Ma114f*4turers Installation gulde MUST be oonsurt2d for multiply wnnectlon details and alternatives All praeum neme9 mm.. tnelerftFka of [noir ro pecrlN! awnam GpRY'Igh! (G)7619.2002 by Keymprk Fnterprlt", IME. ALL RIGHTS RESERVED. Mom T N—th... i Strutt fill WaM Pred UCle 1l79We1eO--ler•PMVklenee Trnpk Unit 1 sunon Ma 01590 H Kcye-dm* Vernion 432 Member Data Description.- Floor Beam Deck Connection: Nalled Live Load: 40 plf Dead Loae: 10 plf DOL: 100% Non-standard Loads Type (Description) Replacement Uniforml'olfl Bob @ Doyle Reynolds Rcs Member Type: Beam Application: Floor Lateral Bracing: Continuous. Moisture Condition: Dry Building Code: Other Deflection Criteria: L/360 live, 0240 total Filename : Bob7,14,03.K Member Weight: 8.9 plf Trib. Live Dead Begin End Width Start End Start 0' .00" 12' .00" 320. 80. 07/1.4/03 12;54p1n 1 of I End DOL 100% 12 0 Bearings and Reactions Input Minimum Worst Case Location Type Width Length Total 100% Dead Total 1 0' ,00" Wall 3,50" 2 1 V6.75" Wall 3.50" 1,75" 2364# 1850# 5144 23644 1.75" 2364# 1850# 514# 2364# Design spans 11' 6.75" Product: 2.0 Rigid.Larn LVL 1-3/4 x 9,5 Allowable Stress Design Positive Moment Actual 6833.'# Allowable Capacity Location Shear 2040,# 13100.'.# 6318.# 52% Max. Reaction 2364.# 9188.#1 32% 25d/n .01, .01' LL Deflection TL Deflecticn .2573" ,3854" U539 0 5,78' 3288" .5781" U422 5.78' Conirol: LL Deflection Manufacturer's installation guide MUST be consulted for multi -ply oonn@ntion details and alternatives Aft produel namoa qre rradehtnrka of [heir rnppeetNe —nm copyrlphr (C)1989-2002 by Keymark Enterprises, Inn. ALL RIGHTS RESERVED. 2 ply Loading Total load 100°x6 Total load 100% Dead load Total load 100% Total load 100% Adam T Northegat Strueturtal Wood produets 1713 Woreearer-Providence Trnpk Unit i Button Mn 01590 1 • �` 70 X fji ILA V M i R p PO5'E 0 � �-f K 1(p 'S V ry (Z a ©vin 9TEVC RS-INOL-05 Cup 6t4 0,T "LfF 46f tisA 11144VtV- P4 �o00- C)()0q'-L- i t 3/y x k'l8 I 6-vV �c I5T19►�+(, ���� �. ��, oil C/) m m m U) 0 c y C � CO)CD C'7 n Z y CD O 'v C.�_ C C CO) � o � c v CD CDCL o Q /� = `D CD O CD _ W w a C CD V; CD CZ O CO) CO CD S v CO) O 'v Z CD O CD C CD I. cn V J O cn CC \ / O ^� C� w O O —• H CT G O < CD N C4 r n w mem! co— m n � ` O cCS C) CP c� b rD O O x n Z S. S•p 0) Vi O� .O•' s m CL� G = T CD CD d S W O m y y N�m O CD 2 > >� c(CD O0 .m H• nccl ` CL W CD y c O 0 CD : V CLO CD ` Y Nd y �CS N CD �cH 4 CD N 1 � � CD O A : ..► O :p i `K 3 N lbCD i A r' CD ; :7 VJ CD d d n�• n 0 c O o' = Cn o, O ^� C� w O G7 roC) w O x r n w O - Tor "'d w � ` O '. . O G CL c� b rD O O x n O O I ON 0 O C ►s ✓, tJ N° 3 3 k. J Date.....�....�.�.......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ..........0 P (� JThis certifies that .... 4—/r.(. ........ :............ ............................. has permission to perform ....................... ' wiring in the building of ........� �. at .,......E ........ .................. ` ....... ........................ f , North Andover, Mass. i' Fee. _......................,....................... ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 014t TIIIIUliIIlirualfh of +Aassar4use##s Office Use 0 Department of Public Safety Permit No. :!�gklr BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy &Fee Checked 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 ,r (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date City or Town of 1\10R-114 itNDOYF,R To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) -`__Ib C�I6,<-, NL;-, S-� Owner or Tenant W C'Eit'1T) -e,(— Owner's Address Is this permit in conjunction with a building permit: Yes LJ No Lt�'— (Check AppropriateBox) Purpose of Building G I—//14M/ Utility Authorization No. 0-7x/ Existing Service �J Amps 2 Volts Overhead 2 Undgrd ❑ No. of Meters New Service I 0 Amps I r4o / NO Volts Overhead R Undgrd ❑ No. of Meters Number of Feeders and Ampacity)�— 3 W i+ tis /60 / - ,-5 y Location and Nature of Proposed Electrical Work EMETJGGIVC! (1)JAJkJ� � �E7ZV/CE OTHER: s, INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ NO ❑ ! have submitted valid proof of same to this office. YES ❑ NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE 1;4" BOND ❑ OTHER❑ (Please Specify) dj- (E iration Date) Estimated Value of Electrical Work $ Work to Start d G I Inspection Date Requested: Rough Final Signed under the pens ties of perjury: J A FIRM NAME LIC. NO. ,3z Y 0 Licensee Signature LIC. NO. Jry/A W Address J� �� Bus. Tel. No. 75-6 5]3- eO36 4 Alt. Tel. No. a _ J L6/ ?— -�—W/ .OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts .General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE $ 33 (Signature of Owner or Agent) TOTAL No. of Lighting Outlets No. of Hot Tubs No. of Transformers KVA AboveIn- [:]rnd. ❑ No. of Lighting Fixtures SwimmingPool rnd. Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners Batte Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Total No. of Ranges No. of Air Conditioners Tons Initiating Devices No. of Sounding Devices. Heat Total Total No. of Disposals No. of Pumps Tons KW No. of Self Contained Detection/Sounding Devices. No. of Dishwashers Space/Area Heating KW Municipal [—]Other No. of Dryers Heatin Devices KW Local❑ Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: s, INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ NO ❑ ! have submitted valid proof of same to this office. YES ❑ NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE 1;4" BOND ❑ OTHER❑ (Please Specify) dj- (E iration Date) Estimated Value of Electrical Work $ Work to Start d G I Inspection Date Requested: Rough Final Signed under the pens ties of perjury: J A FIRM NAME LIC. NO. ,3z Y 0 Licensee Signature LIC. NO. Jry/A W Address J� �� Bus. Tel. No. 75-6 5]3- eO36 4 Alt. Tel. No. a _ J L6/ ?— -�—W/ .OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts .General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE $ 33 (Signature of Owner or Agent) Date ............. 52 .. .. /? ..... r.L....? ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that...... ............... ................ .................................................... has permission to perform ...... . ....... ......... .......................................... ..... wiring in the building of ..:.1 . ..... . ............... ............ ................... at Z(� .......... ......................... ...................................... oAndover, Mass. Fee- ....... Lic. No. ...... /& .................... ELECTRICAL INSPECTOR Check # 1;U 473) THE COA MOAWEALTHOFMASSACHUSE7TS DEPARTAff ANT OFPUBIICSAFETY BOARD OFFMEPREVEMONREGULAHONS527 CARl2 09 Office Use only P���� e�v Permit No. /73��a- `, Occupancy & Fees Checked �.�\ APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRIQ9L CODE 527 CMR 12'OO SSE PRINT IN INK OR TYPE ALL INFORMATION) of North Andover To the Inspector of Wires: undersigned applies for a permit to perform the electrical work described below. (Street & Number) Owner or Tenant Owner's Address Is this permit in conjunction with a building permit Yes F-'7—rNo F-1 (Check Appropriate Box) Purpose of Building h o c— it Utility Authorization No Existing Service Amps / Volts Overhead Underground No. of Meters New Service Amps / Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above M Below Generators KVA round ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local F-1Municipal Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER• IrmianoeCowrage. Rmanttothew maneMofNbmdRs MG=TALaws lbawaamtLabifityknw&)xPbhcyinckxfiTCm4)le�OpuabonsGDvuageorgsabsmntaleqmvakit YES M NO Ibawmbn 2dvandpruofofsametotbeOffce YES If)ouhawdrdw-dYES, pleasein&aiethetypeofcoveWby drddng the box. �1 1NSURANCEL'" BOND OBER (PleaseSpecify) I EVirationDate Eel i—wsTu- ke ul . c EstQr &d Value ofFbctrieal Wodc $ LimmNo.i-- IiCeliSe�/�� SiSiortAn �� J� r _ -� LiNo Bumess Tel No. s C, L"-/- . i`7.4 AILTUNo. qIr- �1.7 '7 - �o 9 y OWNER'S INSURANCE WAIVER; I am aware that thel-ioerw does nothave the itasueance coverage orits sobs tial equivalent as n#ed by Mass<�tchusetts General Laws and that my sign&ne on this peirmt application waives this tegtli mrnt (Please check one) Owner ® Agent ® o� Telephone No. PERMIT FEE $_ &(S— � igna ure o wner or Agent The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02119 Workers' Compensation Insurance Affidavit Name Please Print Location: City Phone # I am a homeowner performing all work myself. am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Comoanv name: Address City: Phone#: Insurance. Co. Policv # Company name: Address City: Phone #: Insurance Co. Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1,500. and/or one years' imprisonment_ vte11_as_civil.penattiesin.sheinrm-d a STOP WORK_ORDFR,and_a fine_of..($1DOSD)a-day against _me t understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification_ / do hereby certify under the pains and penalties of pedury that the information provided above is true and correct. Signature Date Print name Pbone # Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensincl O Building Dept G ❑Check if immediate response is required Licensing Boaid E] Selectman's Okice Contact person: Phone #: ❑ Health Department o Other