HomeMy WebLinkAboutElectrical, Plumbing and Gas Permits - Permits - 45 TUCKER FARM ROAD 9/1/2008 Official Use Only
Commonwealth of Massachusetts
Pemiit No.
Department ofFire S,er
vic'es
F Occupancy and Fee Checked
BoARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blan
APPLICATIONFOR PERMIT TO PERFORM ELECTRICAL WORK
All.work to be performed,in accordance with the Electrical Code(MEC),5 27 CMR '12.00
(PLEASE PRINT IN INK OR TYPEALL N AT N
Date:
City or Town of: NORTH ANDOVER To the Inspector of'Wires.-
By this application the undersigned gives notice of his or hier intention to perform the electrical work descnibed bielow.
Location(Street&Number') L4 T 'Tul J<Roe— F4/,
Owner or Tenant CA A o Telephone No.
Owner"s Address,
Is t?thi's pernuitin conjunction with a,building P er rM Yes No, (Check Appro riate Box)
P,urpuse of B,ufld'g 4L Utility Authorization No. p
in
Existing Service Amps 1 /.24-10 Volts Overhead Und,grid No.of Meters
New Service Amps Volts Overhead, Unilgrd No.of Meters
Number of Feeders and Anipacity
Location and Nature of Proposed Electrical Work
Completion of Me ollo win table may be waived by,the Inspector qf fines®
L .9
No.of Reces is wires j , No.of'Cefl.-Susp.(Paddle)Fans Noll of--- Total
Transformers KVA
No.of Lummiaie Outlets, No.of Hot Tubs, Generators KVA
Above F7 In- 5767, Emergency Lighting
No. of Lurm'nai,res SwiniNding Pool L_J _grnd. Battery Units
No.of Receptacle Outlets, ]Nn. of Oil Bur ners FTP,6E ALA."1L%AJS 1No. off, on
No.of Switches 'No. of Detection and
No.of Gas Burners
'Total Initial evicies
No.of Ranges No.of Air C'on,d. Tons No.,of Alerting Devices
ffeatPunip "N'um"b er"T*o ns No�. of'S"elf-Contained
No.of Waste Disposers a &0
Tot I 01111111111111 I Detection/Alerting evices
No.,of Dishwashers Space/Area Heating KW` -1 Municipal
Loc al10 Connection 0 Other
wr—
No.of Dryers Heating Appliances KW` isecurity Systems-*
Water No., of — No. of No.of,Devicels,or valent
Heaters KW Signs Ballasts Data Wiring-,
Devices or Equiivalent
No.Hydromassage Bathtubs No.of Motors Total HP 'Tele�comm,unicati,oins Wiring:
No.of Devices or Egluivalent
,OTHER:
Atlach additional detail if'desi'red, or as required'by the Inspector of Wires
Estimated Value of Electrical Work,: (When required by municipal policy.)
I --
Wo�r.k to Start:-,k/ f, Inspections to be reque sted,in.accordance with MEC,Rule 10,and upon completion.
]INSURANCE VERAGE: Unless waived by the owner,no permit for the performance of elec try cal work mayissue unless,
the licensee provides proof of liability insurance including"completed operation"'coverage or its substantial equivalent. The
undersigned certifies.that,such cover , e is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE Z71BOND OTHER [] (Specify,:)
,I certify, unde�r thnins a�ndpen tie.v o perjury, that the info atipn on this applicatio n is true and com lute.,
A E* r
FIRM N E.
I Al A. S 1,44 LIC.,N
�,k itA, L Signature 114 NO.:
Licensee-, ,, ) /4
(Y applicable, enter "exempt"t i.n the n nu 11
Address:! A Bus.,Tel.No.
Alt.Tel.No.:
*PQr M.G., C. 147,s. 57-61,security work requires Department of Public Safety"S" License: Lie.,No.
ER"S INSURANCE WAI'VER..- I am aware that the Licensee does not,have the liability insurance coverage nonnally
required by law'. By my signature below,,I hereby waive this requirement. I am,the(check one) 1:1,owner El owner's agent.
Owner/Agent
Signature Tellephone,No. FPEJRMIT FEE# $
/
z.
The Commonwealth of Massachusetts
Department of IndustrW r
Accidents
Office
6.00 Washington Street
._.
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a s
A
tic
ffill
Please Prl'nt Ley
u
Address:Name, (Business,/Organization/Ind'llv,ldual)61.1.,I
City/State/Zip:p.�).�,&,,.,v.,,
zir)
ovv, employer? e appropriate
a Type of projec�t i
I al,lim a empi r with general con for and 1 6. E]Newconstruction.
employees11rn w
2.0 1 am a sole Proprietor or - listed on,the attached sheet
ship .have no employees sub-contractors h°ave 8. Demoliti
working for,rne in any capacity. workers,"' comp. insuran.ce. 9. Ej Building add'iti
I Ion
workers'comp. insurance 5. We are a corporation
r r e s have exercise'them Electrical � r i ions
31. 1 am a homeowner doing all work, right of Plumbing repairsr additions
sells �w . .52, § :and a have no 110 Roof re'Pairs
insurance required.]t employees. workers,"
comp. ins requirecLj
13.
Other
Any ia pil icant that checks bob l rn ust ais o fill out the s ectio Ica r gho w in:g their workers'6o mpm sat ia policy inform tJ,
� n
affidavitHomeownm
, who su,bm�it this u at Iw �d it n j�ti su ch..
a �t t w must� 4 _ rmjisowng, name v � e-u r comp. i,c �viroP
[am an employer thai is pri?viding workers compensation insuratwejor nv,employees. Below a the policy,andjob site
a
information.
Insurance Company Name. A
JwA-� TAI
' l,iy L t Expiratr'
Job,Slite,Address:, L -ru c
tf city/state/z,11.
I
°
Attach a copy"of the workers" s�afl policy ecl . n page(showing the policy number, . it date).
Failure to,secure coverage as required under,Section 5A o,f',MGL c. 152 can lead the imposition eniminal i f
pen; II e
fine $��5 . � r one-year m �� m °, well as civil penalties the STOP WORK E� and
afn
of'up to$25 .00 a day against the violator. Beadvised that,a � y ofthis statement may be forwarded to the Office
Investigations the A for inswrance coverage er fi ati- .
f -
r rh"", andpenaltiese information,'Providedtrue and correct
S*gnatur" e- p < � n _
0
Phony
Offiriat use only, Do not write " : r town officiaL
City or Towno
i Ise
Issuingc
. , . it Department Inspector
Contact Person. Phone
MASSACHUSETTS UNIFORM APPLICATION FOR
IT TO DO,GAS FITTING
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aw
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y�
Date,, PermaltM
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Type of Occupancy:
Educra
Ind
Ins
+e e+. !",.ry" G �,'W
'
New:. Alteration. Renovation, `."J
.° Replacement' w
I
ns Submitted: Yes-, No:
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CO
3: 01 111 �W 0 1 != 2
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MCIco, z co CK, 00 '"�'.9 C* �
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BASEMEN
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FLOOR3Ru OR I I I I
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Installing Can : ar6e_LL i;A
AddTeI
A
Name 11 � � l�", r " ��' Businuess Telephone
have a current workers compe n-sation insurance voli c
Policyit
compensation, s ., State reason, below.
M
INSURANCE
:
I have,a current lia I Ir equivalent
I . . .�..�f
If you have checked
A I'labifity insurance policy Other'type of Bond
OWNER'S INSURANCE
I
WAIVER: r Icensee doLs,,nqt,,have the insurance,coverage,required by Chapter 142 of the
Check One Only
Owner Massachusefts General Laws,and that my signature on this plermlit,application waives,this requirement.
1 gent
information 1,have
lifte, (or entered 9S thils application are true and
Plumbing
Ill a ce installations r r I
compliance with all in r i n � I I e l
�
By Type of License:
w 1imr
Gas Fitter
Tithe
Signature, i se lumber/Gas Fitter
Master
n ".
".�w.
Jour
iyvv man 1 r:1
m
L 'last -
APPROVED USE , ,."" ..„"..
a
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w,
MASSACHUSETTS
UNIFORMII 'I PERMIT TO, DO PLUNIBINGI
a
a«
r� rF
w. .... "i y w�f 1 u� du q "t 'I �" m aMA. Date: w �`� I "r i t
Dui ui
�Iditi
/ dp,;
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d
Typeof � : Commercial Educational tv l Ind striai Institutional El Residential.)
N ew: Alteration,: Ej Renovation-. Replacemen,t: PI n Submitted: Yes I
yf< FIXTURES
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1 �e J .1 W u!( W
SUB BSMT.
BASEMENT
FLOOR
'2c FLOOR
FLOOR' j
FLOOR
5 FLOOD
FLOOR
FLOOR
41,
� 7
at Check One Only Certificate
Installing : �Lit 16
El Corporation
dr �l� it lT' �r A-1 F
El Partnership
0 Is — _'3 B �� ���W.. i
�a. �� s
I � TI �Yp Fax:
,eFirrn/Company
Name of L,icensed Plumber:
INSURANCE COS
I have a current liilit�i � rr� ali r itsIttlrlrt hh the rir� �rlt I" �I_. h. Yes No
If you have checked Yes, please indicate the type of coverage by checkingthe r ri to biox below.
liability insurance policy� " ,,..,.. Other type ofindemn,ity [:1 Bond [:1
OWNER'S INSURANCE I' I am aware that,the licensee dues not have the insurance coverage required bly Chapter 142 of the
Massachusetts hus tts General Laws,and that my signature on this permit application waives,this requirement.
Check One Only
OwnerAgent El
wa�
Signature of Owner or Owner'sAgent
I hereby lcertify that 111 of the d t i I's and information I h�ave s pibmifted( rl entered)r r i � tha� Ir�c tr �r� �� � ��� " r ute t, the Ikb t of my
Knowledgeand that alit,plumbing r4 and installationsrf+ r d unifier the permit�i� l � �t r thl I �l� I r� III�a, °r�� Oa,, w�Gth II
Pertinent f theMassachusetts, State Plumbing Code n C-hapt r 1 theGeneral IL �00't.
W'°r�rrm m��x uumm;m�auw�wnrcu�� ,� r
Type of L,iniis :
Title Plumber Signature of Lice sed PI u
;
Master
City/Town E]Journeyman License per:, „r
—APPROVED OFFICE USE ONLY)
ASSACH SETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
_ - NORTH TH AND OVER 10/
Mass. Date 20 08 Permit
TUCKER FARM D I NELIUS ' NN I
ti Building Location Owner Name
oe
4
30 32 RESIDENTIAL
Owner Tel# Type o Occupancy
v Renovation plc ent Plan Submitted. NoF]
FIXTURES
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W
0
Z Z
z 0
P4 0 0
U)Lu LLJ V) LU ZU WCL4 �4
P4 U)
50 z Lu z
> W-t
SUB-BSMT
BASEMENT
1ST FLOOD
2N°FLOOD
2D FLOOR
r FLOOD
T"FLOOR
"FLOOR
7
T"FLOOD
T11 FLOOD
i
Installing Company l Name Eastern rn Propane & Oil, IncCheck one: Certificate
Address 131 Water Street Corporation
Dangers, MA 01923 Partnership
Business Telephone
-322- 2 Firm/Co.
Name of Licensed Plumber or Gas Fitter .AK COOMES
INSURANCE COVERAGE:
i have a cur liability insurance policy or its substantial equivalent which meets the requirements of I L h. 142.
Yes No
El
If you have c ck d des,please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity 0 Bond D
OWNER'S' INSURANCE WAIVER-l am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Mass.General Laws,and that ray signature on this permit application waives this requirement.
Check one:
Owner 0 Agent 11
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my
knowledge and that all plumbingwork and installations performed under the permit issued for 1 aki apr
r"will b .. compliance with all
rovisions of the Massachusetts State Gas Code and Chapter 142 of the General L w
rtire r
etit p
By Type of License:
•• lumber Signature of t rased P� er or s Fitter
'�as fitter
Title 4
• -,Master License Number --
it /Town -Journeyman
APPROVED(OFFICE USE ONLY)