HomeMy WebLinkAboutMiscellaneous - Exception (86):r
9960
Date.... ..........................
1 N°RT" 1
°•�"`° '• "� TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
This certifies that ...........� ......./. /. ......................
�jS
has permission to perform ...... I G�/�' ...................:..
wiring in the building of ..........
at .......5..........5.7 .................... K
North Andover, Mass.
Sr Fee...S.�...... Lic. No..,�1%5............. f.ELECAL NSP.iFc
1
`` Check #� (// (/�/
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Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. �M6
Occupancy and Fee Checked
Lev. 1/07] fleava �,i�„v�
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 PRINTININK ORTYPEALLINFO TION) Date:
City or Town of#-Rj
By this application the undersvesno ' e of his orThrntentio n perform he electrical workWA To the _hnspector of zescribed below.
Location (Street �& Number) ,-3 �a 1,f 5 S -/
Owner or Tenant A, a, ,'Ll 4, — ,
Owner's Address
Telephone No.
Is this permit in conjunction witka building permit? Yes
Purpose of Building �w c l/i ti ❑ No BLDG PERMIT #
Utility Authorization No.
Existing Service /, l Amps f_/ 2 5� Volts Overhead Eey
�1 Undgrd ❑
New Service Amps VoIis
NuOverheadmb. f F d ❑ Undgrd ❑
X o ee ers and Ampacity
Location and Nature of Proposed Electrical Work:
VrM rte+ 4,v
.7ti
' No. of Recessed Luminaires
No. of Luminaire Outlets
No. of Luminaires
No. of Receptacle Outlets
No. of Switches
No. of Ranges
No. of Waste Disposers
No. of Dishwashers
No. of Dryers
No. of Water KW Heaters
No. Hydromassage Bathtubs
OTHER:
of Ceil: Susp. (Paddle) Fans
of Hot Tubs
Swimming Pool =e ❑
grnd
No. of Oil Burners
No. of Gas Burners
.'*To. of Air Cond. TO
No. of Meters /
No. of Meters
:g table maybe waived by the Inspector of Wires.
.�
Generators KVA
:E3 o. o mergency ig mg
Battery Units
.E ALARMS INo. of Zones
of Detection and
Initiating Devices
of Alerting Devices
yetection/Alerting Devices ;
Spacf
Heating KW Local ❑ Municipal
Connection ❑ Other
Heatpliances KW Securliy Systems:*
No. oo. No. i f Devices or E uivalent
Bal of Data Wiring:
Ballasts No, of Devices or E uivalent
Vo. of Motors Total HP Telecommunications Wiring:
No. of Devices or EauivalPnt
Attach additional detail ifdesired
Estimated Value of Electrical Work: , or as required by the Inspector of Wires.
Work to Start: In(When required by municipal policy.)
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 cover s in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER Sec'
I cert, render th ains nd enaXes o r u that the inform ati� n th
FIRM NAME: �/� f� �7 P n is trace and completes
c ��
Licensee: LIC. NO.: � j`f�1� 5
Signature LIC. NO. --7/72
(Ifapplicable, ent r `ex pt" i t lice n tuber line.)-)
Address: flj /�eG "jQ� P Bus. Tel. No.: d
*Per M.G.L. c.147, s. 57-61, security work requires Department of Public Safety °� L en� Alt. Tel. No.: °7Jf 7G6-�S& 5�
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the cenliabLIC. NO.:
required by law. By my signature below, I hereby waive this requirement. I am the (check one) [] ownerrance co ❑ ownormally
ers afi nt.
Owner/Agent g
Signature Telephone No.
PERMIT FEE: �'
ELECTRICAL PERMIT NO. INSPECTION REPORT:
ELECTRICAL INSPECTOR - DOUG SMALL
1. ROUGH INSPECTION:
Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ]
Inspectors' comments:
(Inspectors' Signature - no initials) Date
2. FINAL INSPECTION:
Passed —x Failed — [ ] Re -inspection required ($50.00) - [ ]
Inspectors' comments:
(Inspectors' Signature - no initials) Date
3. UNDER GROUND INSPECTION:
Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] y
Inspectors' comments:
(Inspectors' Signature - no initials) Date
4. INSPECTION —SERVICE:
DATE CALLED NATIONAL GRID: NAME:
Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ]
Inspectors' comments:
(Inspectors' Signature - no initials) Date
f
INSPECTION - OTHER:
ssed — [ ] Failed — [ ] Re -inspection required ($50.00) -spectors' comments:
(Inspectors' Signature - no initials) Date
DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED.
p. -'k
The Commonwealth ofHassachusetts
UVDepartment of Xndustrial.Accidents
Office of -Investigations
600 Washington, Street
Boston, MA 021YT
www.massgovlctia
Workers' Compensation Insurance Affidavit: Builders/Cori:ractors/JEleciricians/JPlumbers
Naffie(B.usiness/Organization/Individual)://
Address: /,/I � lhkil _4 5 f
City/State/Zip: Pa 4 (/ t K S , Aa &Z-5 Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
full and/or part time).*
yeeols
have hired the sub -contractors
2. Iam a se or partner
proprietor
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
3.0 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.]
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
I I. ❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
'nuy appucant mat cnecxs bOX 41 must also Ul out the section below showing their workers' compensation policy information.
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 isproviding workers' compensation insuranceformy employees. Below is thepolicy andjob site
information.
Insurance Company Name:,
Policy # or SeIf-ins. Lie. #:
10 fob Site Address:
ExpirationDate:
I
City/State,/Zip.-
Attach
ity/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. De advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
X do hereby
that the information provided above is frue and correct.
Date: `G/ /Z
Phone #: C ;1 �5—' v -7 7/-)— 3 2 Z_ / - -
Official use onb) Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
X. Board ofHealth 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
ContactPerson: Phone #: ��
Date.
�T TOWN OF NORTH ANDOVER
is •.� •.'• of
ii,1110
PERMIT FOR PLUMBING
° ,SSACMUSE� ..
-.y
This certifies that .. ......................
has permission to perform ... �,ri.� u.i�{.t...........
plumbing in the buildings of . r .t ......................
at .. 1. .. ��, .. s I ...................... North Andover, Mass.
Fee.Al.? ."... Lic. No..�.2 �. �.G . _. C� .
-PLUMBING SP�ECTOR
Check # �� _�
fi
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
�' " �ry v� /
City/Town: •�!� MA. Date: 3-1 a Permit#
Building Location: _(� w� f Owners Name: Y v c, n a -e
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New: ❑ Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted: Yes ❑ No Cy
FIXTURES
DEDICATED
w Z SYSTEMS
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W
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CA Ln Z F- Y Q of U ��' w O Z
Q CA CO X OC W y �"' Uj
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r O H Q O Q W 0 W Z W J _Z U C LL x J Q Q
C O 3
0 U Z Q W CL Y Q x W W W Cd 0 H W
a m m o oU. x" g g N W 3 3 3 o a 3
SUB BSMT.
BASEMENT r
1ST FLOOR
2ND FLOOR
3RD FLOOR
4T" FLOOR
ST" FLOOR
6T" FLOOR
7T" FLOOR
8T" FLOOR
Installing Company Name: ocli t-. �¢ /� Check One Only Certificate #
o2 ce4fepvo ✓�G -( El Corporation
Address: P2-6 02 City/Town: /t/� u/Faa State `
/' � ❑ Partnership
Business Tel: _ `� o 3 7 Gl y�j 0 y Fax: 916/
❑Firm/Company $tel
Name of Licensed Plumber: �) .t y v k /I
INSURANCE COVERAGE:
1 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 indicate the .type of coverage by checking the appropriate box below.
A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Si nature of Owner or Owner s A ent Owner ❑ 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 pertormed 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.
By �Lr✓ 1�
Type of License:
Title Plumber Signature of Licensed Plumber
City/Town IRMaster
APPROVED OFFICE USE ONLY ❑Journeyman License Number: 1.2 q,76
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information . Please Prinf Legibly
Name (Business/Organization/Individual): . t Gi �rihrt �(yyh f ,j%r`
Address: of (9
City/State/Zip: t4 *`/0" Phone /#: '1"10,3
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).* have hired the sub -contractors
2. I ara a sole proprietor or partner- listed on the attached sheet. # 7. ❑Remodeling
ship and have no employees These sub -contractors have 8. ❑ Demolition
working for mein any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3. ❑ 1 am a homeowner doing all work right of exemption per MGL . 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, § 1(4), and we have no 12.❑ Roofrepairs
insurance required.] t employees. [No workers' 1311 Other
comp. insurance required.)
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. •
t Homeownds who submit this affidavit indicating they are doing all work and thea 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 acid their workers' comp. policy information.
•Tam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: S [ l�
Policy # or Self -ins. Lie. #: Expiration Date:
Job Site Address: U City/State/Zip: /I/���P�� elj/ J
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;i day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance'coverage verification.
Ido hereby certify unr�er the pains anc[penalties ofpefjury that the information provided above is true and cor';ect
Phone #: l4' ,3 0 q G
Official use only. Do not write in this area, to be completed by city or town officiaC.
City or Town:
Permit/License #
_/,9
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
The Commonwealth of Massachusetts
r
Department of IndustrialAccidents
rF,u
j Ii
Office of Investigations
:l€.�•
600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information . Please Prinf Legibly
Name (Business/Organization/Individual): . t Gi �rihrt �(yyh f ,j%r`
Address: of (9
City/State/Zip: t4 *`/0" Phone /#: '1"10,3
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).* have hired the sub -contractors
2. I ara a sole proprietor or partner- listed on the attached sheet. # 7. ❑Remodeling
ship and have no employees These sub -contractors have 8. ❑ Demolition
working for mein any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3. ❑ 1 am a homeowner doing all work right of exemption per MGL . 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, § 1(4), and we have no 12.❑ Roofrepairs
insurance required.] t employees. [No workers' 1311 Other
comp. insurance required.)
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. •
t Homeownds who submit this affidavit indicating they are doing all work and thea 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 acid their workers' comp. policy information.
•Tam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: S [ l�
Policy # or Self -ins. Lie. #: Expiration Date:
Job Site Address: U City/State/Zip: /I/���P�� elj/ J
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;i day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance'coverage verification.
Ido hereby certify unr�er the pains anc[penalties ofpefjury that the information provided above is true and cor';ect
Phone #: l4' ,3 0 q G
Official use only. Do not write in this area, to be completed by city or town officiaC.
City or Town:
Permit/License #
_/,9
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 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 aparhnents 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 ofa 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 cant' 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 pen -nit 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 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 pennit/lieense 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
Policy information (if necessary) and under "Job one affidavit indicating current
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 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 Commonwealth of Massachusetts
Department of Industrial .accidents
Office of Investigations
600 Washington Street
Boston, MMA 02,111
Tel. ## 617-7,27-4900 ext 406 or 1-877-MA.SSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.govfdia
76u�.
Date .. 3//Oy ..........
TOWN OF NORTH AN
100
•
PERMIT FOR GAS 1087
This certifies that ...�� h!??.... ��4..�.......... . . .
has permission for gas installation
in the buildings of . A.f Y ...............................
at . K. 3..' ! . s ................. .North Andover, Mass.
c �
Fee. Lic. No.).L 5 7l . f.. �.�.� ........
,3 0 " • GAS INSPECTO
Check # 411 3 C
M
FIYT"DI=Q
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town: MA. Date:
3 ' « Permit#
Building Location: 6,7 �a�Jl
/
Owners Name:
Cd
Type of Occupancy: Commercial ❑ Educational ❑
Industrial ❑ Institutional ❑ Residential
New: ❑ Alteration: ❑ Renovation: ❑ Replacement:` Plans Submitted: Yes ❑ No
FIYT"DI=Q
INSURANCE COVERAGE:
I have a current liability,insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes V No ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
❑
Signature of Owner or Owner's Agent Owner E] Agent
By checking this box; 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.
By
Type of License:
❑ Plumber
Title glias FitteMaster r Signature of Licensed Plumber/Gas Fitter
City/Town Journeyman License Number:
APPROVED (OFFICE USE ONLY) ❑ LP Installer
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Installing Company Name: ��
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Business Tel: o 3 1/a
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Name of Licensed Plumber/Gas �!
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❑ Firm/Company '5�
Fitter:
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INSURANCE COVERAGE:
I have a current liability,insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes V No ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
❑
Signature of Owner or Owner's Agent Owner E] Agent
By checking this box; 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.
By
Type of License:
❑ Plumber
Title glias FitteMaster r Signature of Licensed Plumber/Gas Fitter
City/Town Journeyman License Number:
APPROVED (OFFICE USE ONLY) ❑ LP Installer