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HomeMy WebLinkAboutMiscellaneous - 987 OSGOOD STREET 4/30/2018Date ..... ............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........................................................................................ ........... / . ...... has permission to perform J, ............ . .......... .... wiring in the building of...... dI6, ............................................................ at ....... ....... *Y.- ,.z ......... .................. -,,j4,ortLhhAAndoverNMIa �j Lic. No. .................... & ............. .. ........... ... MUCAL INSPECrOR Check # � rMjffi�-�)j a �Y tfccommontU01111t al MaJlacl uJaiii, .,tJe�arlmcnE o�...tiro �oroi.ce3 BOARD OF FIRE PREVENTION REGULATIONS O�IICIaI �sL{ ORIj- -- Permit:No. Occupancy and Fee Checked 19�av- (leaveblanki APPUCAT90N FOR PERMIT TO PERFORM ELECTR6CAL WORPA A{1 ivarlc to be performed in newrdance Svidi llieMassa chuscitsE)cetrical Code , 517 CMR 12.t1t} (PiRflS�PRINT1NflOf OR E� L MFORAM77ONj Date: � l �4y City or Town of: h. 0 (/Q r- To the Inspec or a kYires: By this application the undersigned gives notice of his or her intention to perform the electrical wort: described below. Location (Street eu Number) cl Z -4 b- � ed,rJ M4- OwnerorTennnt Ar_ C%.. les Teleplrone No. Owner's Address 'f B 2-A t Nw �i^r/�w� Is this permit in. conjunction with a building permit? YesNo ❑ (Cibeck Appropriate Dox) Purposeofl3ai)ding QLn� lJt 4�c.a. Utlity Authorizntion No. Existing Service Amps / Volts NeNV Service Amps / Volts Number or -Feeders and Ampacitf- Location and Nature of Proposed Electrienl Worla Overhead ❑ Undgrd ❑ No. of Meters Overliend ❑ Undgrd n No. of Meters 4- a I '-K �J oI L Completion al'the folloiving Table matr be lvofved by the Inspector oh- No. of Recessed Luminnires No. of CeiI-Su addtc t�nns �' �' ) No. °f Total Transformers ICVA No. of Luminnire Outlets No. of Rat Tubs Generntors lCY No. ofLgminnires Above In- 5�vimmingPool erred. ern d. 114n. o , mergency Lrg Ong 33nttc Units No. of Receptncla Outlets No. of Oil Burners k ALARMSJJ No. of Zones No. ofSwitches No. of Gas Burners No. InDetectian and nitiatint=_ Devices No. of Ranges No. afAir Cond. Tobi Tons No. of Devices g No. of Wnste Disposers lientPump Totn)s: I PLum,ber Tonsl �V o. ofseit=Contained Detection/Alerting Devices No. of Dishwashers Spnee/Area Heating 1tW Local ElMunicipal El OUrcr Connection No. of Dryers Beating Applinnecs ICW Security Systems:= No. of Devices or IJ quivniont No. of Wnter I Heaters No. of No. of Signs BnIlasts Data Wiring: iS- No. afDevices OrE quiv.ilent Na. Hydromassage Bathtubs No. of Motors Tota[ HTelecommunications Wiring -.P S No. of Devices or Equivalent Attach additional detail iif desired, or as required btr dee Inspector of 1 Estimated Value ofElectricai Worle $ 3 k (When required by municipal policy.) Work to Start: 1,60, L.Inspections to be requested in accordance with IvIECRUle 10, and upon completion. INSURANCE C VE GE: Unless waived by the owner, no permit for the performance oFelectricat worts may issue the licensee provides proof of liability insurance including "completed operation" coverage or its subsiantial equivalent. 'I C undersigned certifies that such coverage is in Force, and has exhibited prooFoFsame to the permit issuing office. S CHECKONE: INSURANCE 0 BOND ❑ OTHER ❑ (Specify:) 1 cet7, ttuderUre pnitts and p;rrnlliofperjrtry, that the itrjornrriliat on lltJs trpplicotion is lrltr ttlid cofuple[ YMM NAME: V t �n a t't/ �-`T • �c�. S to 1 ✓� 3�-�� LIC. NO : I Licensee: Signature LICNO. (lfoppllcoble. enter "exempt" in the license number line_) T $us.3'aI. No.; Address: AiG Tel. No_- *PerNI.G.L. c, 147, s. 57-61, security wo equires Department ofPublic Safety "S" License: Lic. No. OWNER'S INSURANCE W� aware that die Licensee does not have the liability insurance coverage norm: required by law: By r signature be--1DwJ hereby waive this requirement I am the (cheek one) ❑ owner ❑ owner's t - ' Signature RootTelephone No. PER M727FEE: 9 I - ) -- 74 � ) f / C OT A, S4 CHU Town of Andover Massachusetts 36 Bartlet Street Andover, MA 01810 Electrical Inspector Paul Kennedy (978)-623-8306 ELECTRICAL PERMIT FEES Fax Number: (978) 623-8320. (revised September, 2012) Office Hours: 8:00 am. - 10:00 am., Commercial Base Fee $50+ $1 each device Residential New Dwelling Up to 200 amp service $225 Each add. 100 amp's $20 Multi -Family New Condo/Multi-Dwelling (per unit) $225 Residential - Service/change/ alterations I phase - 200 amp $60 3 phase - 200 amp $110 Multi -Family/ Single Family Each add. 100 amp's $20 Additions/Renovations/Replacements (Maximum Fee $225) $50 (min. fee) Outlets, switches, plugs, luminaires, etc. $ 1 each device Residential Appliances $50 (min. fee) Commercial ($50 base fee+) $10 each appliance Air Conditioning and Heat Pumps $50 Temporary Service $50 Residential Generators/Solar Panels (service additional cost) $100 (base fee) + Additional Equipment $25 each Commercial Generators/Solar Panels (service additional cost) $100 (base fee) + Per KVA $1 + Additional Equipment $25 each Residential Audio/video/data/phone-systems/ $50 Fire alarm/security systems Commercial Audio/video/data/phone-systems/ $50 base fee + Fire alarm/security systems $60 Commercial New Construction and Alterations Base fee S50+ Per 1,000 sq. R. of Construction Space $100 Service/Change up to 200 amp $150 See Electrical Its pector,for price above 200 amp Maintenance Permit/Repair Blanket Permit (up to two electricians) $200 Over two electricians (per pair) $50 Office Furnishings/ Partition Relocations $50.00 (base fee) + Per Circuit $10 Transformers (non-utility owned) $50 Miscellaneous Carnival rides $50 Demolition $50 Feeders or sub -feeders and panels $30 (each 100 amp. capacitor fraction thereof) Motors, per hp or fractional par( thereof $4 Siding (re -securing service, lights, plugs) $50 Signs $50 Meters $20 Swimming Pools In -ground $100 Above -ground $50 Commercial $200 General Fees Re -Inspection Fee $50 Inspection after hours (minimum fee) _77F7Double $200 iWorking without a permit Permit fee Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked Lev- 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NMC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATIOA9 Date: 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) Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service New Service Amps / Volts Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Completion ofthe 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 K'VA No. of Luminaires Swimming Pool Above rnd. gr El El . ElUnits No' o mergency ig tng Batter 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 g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Dis posers p Heat Pump Totals: Number - Ton s KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑Municipal ❑ Other Connection No. of Dryers y Heating Appliances KW Security Dys evic s:Y No. of Devices or Equivalent No. of Water KW of No. of Data Wiring: Heaters Si s - Ballasts Signs No. of Devices or Equivalent 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 q .f 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 and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: Signature LTC. NO.: (If applicable, enter "exempt" in the license number line) Bus. Tel. No.: Address: 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 her ;dive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature 'Telephone No. j. ❑ 2012 Massachusetts Electric:.. endments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, tke 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 r .. 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 of -ongoing construction activity, and may be -deemed -by the -Inspector_of_Wires abandoned-and-invalid.if 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 purpose 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. ❑ Rule R—Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass (] Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ' ROUGH INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass EN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: :. Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com Date ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING /V certifies that ... ............... 4.�a This cert .......... ... .. ............................................................................ has permission to perform . ................. wiring in the building of .. .... ............................ ...... at, :�....'North Andover, Mass. . ...... ..... .................. A Fee..? ... Uo— Lic. L"..11667 A ...... 1 ..4 ...................... No ................ . .. .... .. .... .... ...... .... ... ,EcrwicAL INspEcro Check # 7-01 P' Commonwealth of Massachusetts official U` she Only Permit No. Department of Fire Services Occupancy and Fee Checked' BOARD OF FIRE PREVENTION REGULATIONS [Rev. I/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: 12- q - vol ? 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) �?g z a-51� et5l,151 56--e-4 / 01P Owner or Tenant C Telephone No. Owner's Address s Is this permit in conjunction with a building permit? Yes Pr No ❑ (Check Appropriate Box) Purpose of Building k t e 's Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service La S Amps fa® 1.2019 Volts Overhead ❑ Undgrd ®" No. of Meters ,Z_ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table maybe waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool rnd. ❑ rnd. ❑ o. o mergency Lig ttng Battery Units No. of Receptacle Outlets G S No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches 247 No. of Gas Burners No. of Detection and Initiatin oDevices No. of Ranges No. of Air Cond. j TonTots /Z -No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: I ITons I--- ""* "['"*"'"'­ IKW 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 KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent 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: as , �� (When required by municipal policy.) Work to Start: /.2- 9- 0o i p Inspections to be requested in accordance with NEC 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 thepains andpenalties ofperjury, that flee information on this application is true and complete. FIRM NAME: _ 7 LIC. NO.: Licensee: .1 L K{ Wy % 4 - Signature oolj, LIC. NO.: D (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.• a/-) )/` oZrZ Address: /9/ 4e -c%,// -rTAel--s4u y p4h* Alt. Tel.No.:97.fr-�S��/p *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 PERWT ME. $''- Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the 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. .M `�Permits.shall-be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if 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 purpose 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. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: / Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: ,j Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F71 Failed 0 Re- Inspection Required ($.) ❑ Inspec rs Comments: GL Inspecto s Signature: Date: ROUGH SPECTION: ` Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspector mments: Inspectors Si ture: Date: FINAL INSPECTI Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comment Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts - Department of IndustrialAccidints Vffl 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): �.� c a[ ,ate i v ax 00 Address:��e City/State/Zip:r ,e i,� �..� Vy1,�a Phone #: Are ti an employer? Check the appropriate box: 1.L1 I am a employer with 0 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. [] Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roofrepairs 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 aie 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:. H'1 LJ Policy #or Self-ins.Lic.#: lti -ul(2 77L7296` 8-20O/3 Expiration Date: fob Site Address: ?*7 z:, o Q '�+yer_/City/State/Zip: Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of 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 certiry under the pains and penalties of perjury 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 #: 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 employeils 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 -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 that this affidavit maybe 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 (if necessary) 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 Comn oaweaMofMassachusetts Department: ofZndustdaf Accidents Office of Investigation 604 Washon. Streit Boston} 1kMA. 02111 Tel, # 617-727-4900 ext 406 or. 1-877r ASSAFB Revised 5-26-05 Fax # 617-727;7749 �vw.�ptass.govfdia. V Datelt2.f.pjl�.. ...... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Thiscertifies that ....................... .................. .......... . 1� ......... ...... i ..................................... has permission to perform..,..: ..... ... kifz,.1.4o�-Z........... plumbing in the buildings o �...:Vc.lvl ... os ... ...... . ..... ....... at ......1.9.... +.................................... North Andover, Mass. Fee4�'nl..-'.'... Lic. No. ..NifY ............................................................... PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - _ CITYTji_A—A-Dp Eli _ I MA DATE __lI .t_ PERMIT# 1e JOBSITE ADDRESS 9$"j �-Oo1J $ , . - _ OWNER'SNAME .1 C ,o+n ! S Be veav—_ POWNER ADDRESS -- _ _-- _ _ _ TEL __ _ _ _ -._l FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL DJ sQ 4} PRINT ~ n A1r- CLEARLY NEW: RENOVATION:[ REPLACEMENT. 01 OFFIC r- PLANSSUBMITTED: YEST--11 FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 ii 12 13 14 BATHTUB CROSS CONNECTION DEVICE _3-__I _ DEDICATED SPECIAL WASTE SYSTEM __-� — I _ __ —� —_ —1 —_E -_ •_, I ___ 3 DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM I I _) DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK -- LAVATORY , ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET_ URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES \ WATER PIPING OTHER7,, - - - _._.-_._i(+ 1 I ' INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I u OTHER TYPE OF INDEMNITY 0 BONDE] 41 OWNER'S INSURANCE WAIVER: i am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the permit issued for this application wi8 be in compliance with all Pertinent provision of the �. Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME -C -L .... . _.__..�.- _- LICENSE# �0 .. SIGNATURE MPD JPOr CORPORATIOND# PARTNERSHIP D#�.__. LLC[�I# COMPANY NAME ._ l log, ADDRESS .:. k/`� CITY -L STATE ®ZIP TEL FAX — __. _ CELL ;�---auga� EMAIL--- i4'1.3�'t .l•l+rl� $_ ,'..` _1`. �� + yT t''_ {_. _r C ! i, `% i ., `_ 1 .. ` r ' •`' - r ., y •,r rl X16 + a / r f E 1 � i`' _ .#' . _ '_ '_ + EE' , _ ..._ _ j '.eJ� v ;?1111 .. rl }•} � , '1 I +S. � �l# ' i_•.. 1 ..�, •} .�' _. T ..r• � t + � � •1_ � �{7! `.'�.�t�.�lt''� _�h'f(�„l,l ~.; ..i.. — '^t - - .; 1 H •1 ____ lr: I ,. iV 14 i_'0 .T_Y,iY A1n ITO /•r ,. , L. .f:. - .� a•� I��il 'a •i.'.�.. .. ?4�h �1 �,1 i 7+".� :1 i ��i� •�'i _�.. „•,}. :�; } ,� «,f.l,_ . � i , � s1 :C _..; 11 `! � fl hil.ft) ! ., ' i1L•!1� .v , ':'• a'1''.,,IV rill•IU 1 � : _. �rir' . 11�f- . _ t . � • e ,IV n � �,1 ..,1 �.,n r c J 1 ' + ', -. • y �, • , t .r' -1 � � iii 1 ' �C '� 1 1 . s ' •l 1 t'4•• ; a..l a• !� 1. .• : r .H-^'... •. r' '; 7 M, r.. 1 . •, }. F r1, , Date... .......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION MThis certifies that............'..C........k"o olveA.:............................:.......... ...................................... has permission for,gas installation ..' % . !.., ................................... in the buildings of ...1). .:,....�-�. k cx'l S..... � e 1-!!' ........................ at .....5!0..... cam.`- � ... ::...................�, �No»rtl Andover, Mass. Fee..��........ Lic. No...�. pZ.6.!'......:............................................. GASINSPECTOR Check # 90.02 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITYor _._ ___ = 3� MA DATE-�,?GT-13 PERMIT# Z" JOBSITE ADDRESS ? _Q (�Q�J) - T•_ __--jOWNER'S NAME Qi�,_G/fig�-� es heti ,g - �--- FAX OWNER ADDRESS TEI f_ __ _--- - �____ TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL' EDUCATIONAL [] RESIDENTIAL CLEARLY NEW: RENOVATION: [j REPLACEMENT: PLANS SUBMITTED: YES F.1 NO R APPLIANCES 1 --FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILERL.J_) BOOSTER CONVERSION BURNER COOK STOVE i _ DIRECT VENT HEATER DRYER .J J _ _ 1 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE- -- --_--•-- --- __ I _,I .—__ __. _.___-� -___J ____I .___.^J .__.._ ___..-I .__ ___ __....._.( INFRARED HEATER LABORATORY COCKS _ _J ___...._. MAKEUP AIR UNIT - OVEN ^�_ J _I POOL HEATER ROOM 1 SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER J INSURANCE COVERAGE have a current liab_liab_ ilfty insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES &]-NO P IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY 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 AGENT (-j SIGNATURE OF OWNER OR AGENT `; I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r PLUMBER-GASFITTER NAME �r - LICENSE #I., oz SfGNATURE JM1� r �---- MP0 MGF L.11 JP JGF Fj LPGI © CORPORATION ©# PARTNERSHIP D#t== LLC COMPANY NAME: iCAAd /.�M/#rgeL..Plu tB+�r.. Fill ADDRESS — — _ CITY '/Le -7.w-- --- ---_ ...._....-.-.� .�._-STATE-_#ZfP FAX _CELLotl -58/ o� EMAIL s ���__ _ r The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 IV www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): /GA AeC %4 f} fZee[ PLym 3 el' / GA'S r-7'%%C�/' Address:200 4625#AW im I e //PS7-Pr MA. n1 1 r2 Z/ Phone #: .SOA Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ®New construction employees (full and/or part-time).* 2. N I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g, ❑ Demolition workingfor me in an capacity. y p �'• employees and have workers' 9. E] Building addition [No workers' comp. insurance required.] comp. insurance.: 5. ❑ We are a corporation and its 10. El Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.0 Other employees. [No workers' comp. insurance required.] *Any applicant that checks 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. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_ r4,e &ArTFor D Policy # or Self -ins. Lic. #: G S 14/ E CCRZ / /B - 001 Expiration Date: I /-A _— / 5/ Job Site Address: 0/97 OS &-cy Q_ 57, City/State/Zip: NOTLTl+ h vDDY>°r ' a181/4, 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. O�i-Jr�il- O Oficial use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # /",;?-,6'/ Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone ©lUi ti 1VW RLTi �� MASS-ACHUSET't'$ v King Design Assoc., Inc / 153 Hay Meadow Road / No. Andover, MA 01845 (978) 852-7882 Architecture / Planning / Interior Design e-mail.- moWonhaymendow@yahoo.com DATE;T NUS' ROUGHING INSPECTION LETTER TO: 'j vg j- 1�h1DO\A F, BU ILDIWC-) C-0 M MfSSIONE.(� RE: $u lL- DoUT nF NE --w VE*jT�*t DFF-Ic S t=ocz Pty, GHhfZL E -SS EW—L-1V U Ar 96-7 0S6 ooA STF-E�-T PSA SED UPO►.S PLAN S PR- AR -F -D 5Y KI WCo DF.SI6jj AioSOG, I i mtG DEAR: M (Z- , CX1 M M 1 SS I nN W—R-1 I INSPECTED THE PROJECT NOTED ABOVE TODAY. t -6-I 0 qz THE FOLLOWING HAS BEEN DONE TO DATE IN COMPLIANCE WITH OUR DOCUMENTS: 94Dv6H r -1'x -A M I WG/F- C^I, -Zp 1,_.0 r-tt5 N em PLEASE CALL ME IF YOU HAVE ANY QUESTIONS. THANK YOU. SINCERELY, KING DESIGN ASSOCIATES, INC. DAVID A. FARMER, AIA ARCHITECT