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HomeMy WebLinkAboutMiscellaneous - 129-131 North Ramp Road i f Date... w.�............... OF NORTF��4 TOWN OF NORTH ANDOVER F � 9 PERMIT FOR GAS INSTALLATION BS.�CMUS� This certifies that . .............f !............ f....... �P . . .. . . . . . . has permission for g installation ... ....1(�..1� �.►. , �... in the buildings of. ...�1.r... zz��...............al ... .•• .... tlSP�Pv, A.........� ?.�.. ..... Nh Andover, Mass. Fee.� ...... Lic. No. .....I .. t"! .................................................... GASINSPECTOR Check#� _ 4 �.— MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITYI..._ .,o MA DATE Lh •1.b J PERMIT # Il/y llf�' JOBSITE ADDRESS I/31/Vt¢�� R� ROeeuL lltw, - p Q, NAME 1' )_,_-)OWNER'S IrIHT`PJ/'1 PA OWNER d��Z•'J . tJr OWNER ADDRESS I' 7 _ 6 `1�,.T{tuu i nRrk LAY.,7cx er N�f Gia TEL E l ' _..--- "I'YI'L U12 1 I'121N"I OCCUPANCY TYPE COMMERCIAL EDUCATIONAL _ RESIDENTIAL] CUCIARl"v NEW: L RENOVATION REPLACEMENT: ;•„ PLANS SUBMITTED. YES] NO J APPLIANCES 7 FLOORS— 8SM 1 2 3 4 5 6 7 8 9 t0 tt 12 13 14 BOILER _.._ _...._._ -.._. . __.. . BOOSTER CONVERSION BURNER - — COOK STOVE - - -- - - -- DIRECT VENT HEATER DRYER FIREPLACE -=- ---: FRYOLATOR -"' r--- - - FURNACE GENERATOR -- --- GRILLE ' - r-- -- - — INFRARED HEATER ------ LABORATORY -LABORATORY COCKS - MAKEUP AIR UNIT OVEN __•.... .. _ - -- -- -- --- -- -- POOL HEATER _. ROOM I SPACE HEATER - `- --- -` - - 7 F200F TOP UNIT --- _.. _ TEST .. . .UNIT HEATER - -- - UNVENTED ROOM HEATER --"- f -- - - - Vv` ATER — - --- — -- ... . .. . . . . . .THER t INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ( NO I d YOU CHECKED YES. PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW \ LIABILITY INSURANCE POLICY I' OTHER TYPE INDEMNITY �1 j BOND L til OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts Gencral 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 Ihal all of the details and information I have submitted or entered regarding This application are True and accurate IO the best of my knowledge and Thal all plumbing work and installations performed under the permit issued for this application will be in compliance w Peninenl provision o(1h Massachusells Slate Plumbing Code and Chapter 142 of the General Laws. / PLUMBER GASFITTER NAME I ,q.. lqTV S 7-4 LICENSE #l?O� SIGNATURE MP ,., l MGF IIF,,,.. JP .1 JGF LPGI; CORPORATION i_-�#L.. PARTNERSHIPi___�#�_ LLC U#L- � COMPANY NAME -.i ADDRESS�IC�D_.CeY.y. CITY L!,. l �.Y1 ✓C2:. STATE ZIP O17 5 TEL � I. FAX( o$_)(4 CELLI EMAIL _.• _..__ . ,_� _ _._ 1 int �, p . �-�„ I � /`1 / !3 GK - „��✓h�, -x The Commonwealth of Massachusetts Department ofIndustrigl Accidents Office of Investigations to 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/Organizationgndividual): Q, SV 6—Q b� ,J O fZoP4,J a- Address: )oo Cycarrz ki c.c._ 2ZJ City/State/Zip: MA-i2Lt3oTwo G-(r, Phone#: S70 6'4 <XYZ) A-fey ygu an employer?Chec e appropriate box: Type of project(required): 1 I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction f employees(full and/o e).x have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.z �• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in 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.❑ I 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,❑Roof repairs insurance required.] employees.[No workers' 131J Other comp.insurance required.] 1 . *Any applicant that checks box#1 must also fill out the section below showing theirworkers'compensation policy information. T Homeowners who submitthis affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an employer that 1s providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: IVA 2 S 6 (/.S A- Policy 4 or Self-ins.Lic.#: N Zr— ¢,o A ,4/„/,0 -» Expiration Date: S -4 i N S 2 e Job Site Address:_ 13 / &OPT k7 C->A nir P R City/State/Zip: /V A w,Uov C f% 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 ofthis statement maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. Ido hereby certtounder thepains andpenalties ofperjury that the information provided above is true anti correct. - signature: 0 �• K FA- -7'.Sr('�-- Date: O 40— /'3 Phone 4: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License ff Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector 5.PIumbing Inspector 6.Other - - - Contact Person: Phone#: Information and ffustrIUIdion's Massachusetts General Laws chapter 152 requires allemployers 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 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 oiut 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(cs)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 LL C 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 Blease be sure that-the affidavit is-complete-andprinted legibly: Tkie:Departmenfhas proiided a space at the boffom 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 permithicense number which will be used as a reference number.-In addition,an applicant that must submit multiple permit/Iicense applications in any given year,need only submit one affidavit indicating current Policy information(ff 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 maybe provided to the applicant as proof that a valid affidavit lion file for future permits or licenses. Anew affidavit must be filled out each ear.Where a homeowner 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. e Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, lease do not hesitate to give us a call. • he Department's address,telephone and fax number: Tho GQrnzA0xjW0ajt of Tassa.,rh setts - Dep.artmextt ofZndustoial.Acel eats Office of In mffgalaons 600 Waski ngtw Street Boston}MA.021.11 Tel,#617-727,4900 at 406 or 1:-877-MASSME Revised 5-26-05 Fax#617-727;7749 1 COMMONWEALTH OF MASSACHUSETTS PLUMBERS ANL <aASFITTERS i LICENSED AS AN L-1 GAS INSTALLER I ISSUES THE ABOVE LICENSE TO: C I PAULO F BATISTA A { 527 LINCOLN ST k � ' I MARLBOROUGH MA 0 -' 75-2-2088 9� ! 3082 05/01/14 160455 i i 72 �0 lVole Rim NAME ADDRESS SERVICE AMPS/VOLTS NO METERS NEW_CHANGE PERMANENT TEMPORARY_ ADDITIONAL: OVER UNDER PERMIT NUMBER SR# ELECTRICIAN RECEIVED BY DATE CALLED _ WILLY WAY - - - e - - - - 4SA-FE-rY WAY BUILDING TYPE!NAME TE '�- -/ DDRESS WILLY WAY NEWENGLANDAVIATORS 97fWILLY WAYNEW ENGLANDAVIATORS WILLY WAY NEW ENGLANDAVIATORS 971 / 40 WILLYNE WAY W ENGLAND AVIATORS 971 I NORTH RAMP ROAD / I 2-• ��1,—'— / BUILDING ROAD BUILDING TYPE l NAME TE / NUMBER I X1075 / FIRE SAFETY AO RES NORTH AF NORTH RAMP ROAD NORTH ANDOVER HANGER ASSOC 971 11q NORTH RAMP ROAD NORTH ANDOVER HANGER AS 1 971 12a NORTH RAMP ROAD NORTH ANDOVER HANGER ASSOC 97i 40 96 a 134 NORTH RAMP ROAD NO R.AND2VERHANGER ASSOC 971 144 NORTH RAMP ROAD ;, t .OIL TYP. ,. _ 158 NORTH RAMP ROAD WTFTML ND OVER HANDER ASSOC 971 9T \ LC 97, �•. WILLY.WAY EAA 78 ` 119 NORTH RAMP ROAD' OPEN 1 1ze t1s NORTH RAMP ROAD / 121 NO PRO 0 135 NORTH RAMP ROAD A KNEW REALTY TRUST BT 121 / NORTH RAMP ROAD MACLEOD AFTER HOURS 971 1135 c MOTORIZED SLIDE GATE, '131 NORTH RAMP ROAD AIRNEW REALTY TRUST 79 ..P 14 — —�.\ ACCESS CODE REQUIRED 12B NORTH RAMP ROAD AIRNEW 141 REALTY TRUST 79 LAWRENCE I 124 CLARK STREET WATER -- :NT PLANT " V I I 4 P 144 BUILDING NUMBER STREET BUILDINGTYpElNAME Tf O� 1 154 1FIRE SAFETY ADDRESS I O 250 CLA 56 RK STREET IFLIGHT LAND DATA 61' �.. I CENTERUNE OF NORTH RAMP ROAD LOCALIZER ROAD MTORIZED Ic SLIDE GATE /\ BUILDING o 1 WITH YELP / NUMBER ROAD BUILDING TYPE/NAME TE TRANSMITTER — / SAFETY ADDRESS 1 LOCAUZER ROAD FAA NAV AID SHELTER SS CLARK STREET / MANUAL ACCESS GATE LOCKEE 1� Q I \ LOCAUZER RUNWAY 5-2J N ® ���` ROAD D O 1 / I II i .o MAIN *1993 TAXIWAY ACCESS CATE �P WITH CARD +1203 READER/TOWER / OVERRIDE ♦1863 RERLINE OF MAIN STAGING / I '`'• RAMP ROAD AREATRANSFORMER TYP. J TRANSFORMER T r1975 ♦1863 C= 0 ig 0 Q- $e OIL TYP. j I MANUAL SLIDE c r q GATE, LOCKED, ` 0 120 B3 +1075 dZ NO AIRFIELD 2B ACCESS — — ' Date.................................. ! NORTI� °f t"`°;•�"� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING CHU DThis certifies that ���,� CJC. � has permission to perform .............................. wiringin the building of 8 ........... ............................... 3 /7/6i s� r'1 .-) ,North Andover,Mass. at... ............e. .................................. x Fee. .... Lic.No ........... ... —4— .. .........,1? 1�....... ..�ELECI'RICAL INSPECTOR I Check # �2" 7J � � U Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. �-57/ BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked L [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 PRINTININK OR TYPE ALL INFORMATION) Date: I Z - Z Z - 06 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 e .S Telephone No. Owner's Address j;Gt fTj La <�U�-e- Is �(Check Is this permit in conjunction with a building permit? Yes ❑ No APurpose of Building /�t Pl �G� PPropriste Box) r 1 Al� (� Utility Authorization No. 6-&7'j Z Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No.of Meters New Service Q� Amps f 1� /220 VOs Overheadlt ! ❑ Un[lgrd� No.of Meters Number of Feeders and.Ampacity �� t.•t 4 Location and Nature of Proposed Electrical Work: CO—7-1-n of the followin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans 1140.01 Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In ❑ o,o me. ency ig g d• rnd. Batte Units - No.of Receptacle Outlets No.of Oil Burners FERE A,AIMdc INo of Tones No.of Switches No.of Gas Burners No.of Detection and Initiatin Devices No.of Ranges No.of Air Cond. TonTots No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: - Detecti on/Alerting Devices _ A No.of Dishwashers Space/Area Heating KWLocal❑ Municipal V Connection ❑ mer No.of Dryers Heating Appliances KW Security Systems:* $ No.of Devices or Eq uivalent No.of Water No.of o.of Data Wiring; Heaters ' Si nIns Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunication.Wiring: OTHER: No.of Devices or E uivalent 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: I Z-2 Z-OD 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: v 6-AlA! LIC.NO.: Licensee: _J p,s ee a"' gnature (If applicable, e ter �"in the lic�nse number li e.) LIC.NO.. I Address: 1ti 1 ,Bus.Tel.No.: *PerM.G.L c. 147 s. 57-61 se riworrequires D Alt.Tel.No.: 6!7 S! i3?�S3 ty k re q Dep ent of Public Safety"S"License: Lic.No. OWNER'S INS CE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. y signa. elow,I hereby waive this requirement. I am the(check one) ❑owner ❑ owner's agent. Owner/Agent Signature Telephone No. i6 PERMIT FEE: $ i I �L aK i t 1 � rte. a �. I Ste--7��- , �� �_����� 1 �� � � x j - _ ., 1 I I The Commonwealth of Massachusetts Department of Industrial Accidents ks Office of Investigations i1 600 41'ashington Street Boston, MA 02111 www.nznss.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print LeQibl Name(Business/Organizadon/individual): �ff Address: 1 S7 Il. 1 �i� �?/►-- l/� City/State/Zip: Phone#: . l 7 l 3 2 S Are you an employer?Check the appropriate box: I.111 rim a employer with 4, ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2�`I am a.sole proprietor or partner_ listed on the attached sheet t 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. Demolition working for mein any capacity, workers' comp.insurance. 9, Building o worker ❑ addition [N s comp.insurance 5. ❑ We are a corporation and its � required.] officers have exercised their 10•❑Electrical repairs or additions 3.F-1i am a homeowner doing all work right of exemption per MGG 11.❑ Plumbing repairs or additions myself. [No-workers'comp. C. 1.52, §1(4),and we have no 12. Roof insurance required.]t ❑ repairs �! ] .employees. [No workers' 13.[]Other comp. insurance required.] *Any applicant that checks bot d(must also fill out the section below showing their worker:'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. $Contractor;that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy irfsr„a iaa. lam an employer that is prmriding workers'compensadon insurance for n7y employees. Below is the informapolicy and job site tion. 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 civil penalties in the form of a STOP WORT[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 ce ify under the p insenalties of perjury that the information provided above is true agn�d correct Si afore: Date: 2 ”� —D Phan 7alDOfficial oonly, Do not write in this area,to be comlpleted by city or town offciaL n: Permit/License 4 ority(circle one):ealth 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspectoron: Phone 0: 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, I 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}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 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 I52, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into a iy contract for the perfon lance ofppublic work with acceptable evidence of,ioi,ipliance with the irisurance 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,notthe 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 numberlisted below. Self-insured companies should enter their self-insurance license number on the appropriate line. I City or Town Officials I 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 ofthe 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 citireu is obtaining a linens- or permit not related to any lrssiness or commercial v;:nture (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 as a tail. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #6I7-727-4900 ext 406 or 1-8.77-MASSAFE Fax#617-727-774.9 Revised 5-26-05 wwW.mass.gov/dia I Date......`., -. .... f NOR7F�, o?°.<�``°.;•�."ooh TOWN OF NORTH ANDOVER PERMIT FOR WIRING 'TSA US Phis certifies that �� E �/ !�.(�.`s`' ... . has permission to perform ...f?.l�Aep. 7/� � Aft �1/�<v lsE�l�.r`y 72vsr wiring in the buildin 3 o9-W 7. ................................ � ..... at......../�z..�!.`� ny....4�f4-1,9... .0 'A............,4jorth Andover,Mass. Fee t ..t....... Lic.No.c.. 7..... ......... !�.�/..�. .f. y .... �r ELECTRICAL INSPECTOit� Check # — r 7467 i Commonwealth of Massachusetts Official Use Only Permit No. 7 /3 w - Department of Fire Services p 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 CM .00 LEASE PRINT IN INK OR TYPE ALL INFORMATION) 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) / ZVf Owner or Tenant Telephone No. w � � p � S ----Owner's Address W Ile- (JS i` MIV U , 4& Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building 7414 k/ f& Utility Authorization No. 2.&35 35 Existing Service Amps / Volts F Overhead ❑ Undgrd❑ No.of Meters New Service Amps 1(0 ICV Volts Overhead ❑ Undgrd No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: r Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires U 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 o.o mergency rg ung rnd. d. Battery Units Q No.of Receptacle Outlets b No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.o Detectio°and Initiating Devices J ' No.of Ranges No.of Air Cond. Tonal No. of Alerting Devices No.of Waste Disposers Heat Pump I Number I Ton W No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local Cico nnnenctioatio El Other Con No.of Dryers Heating Appliances Security Systems: No.of Devices or E uivalent No.of Water No.of No. Data Wiring: Heaters Signs Ball - No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP elecommunications Wiring: 92. wP No.of Devices or Equivalent Tp 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 CO E AGE: 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 exh' ited 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: Q k T- tG4"� LIC. NO. 73q Licensee: Signatur LIC. NO.: (If applicable,e r "e em "in the l' ens�n r li e.) us.Tel No.: Address: Alt.Tel. No . *Per M.G.L c. 147,1. 57-61, curity 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 ins ance coverage normally required by law y my sign e below, 1 hereby waive this requirement. 1 am the(check one)[owner ❑ owner's agent. Owner/A en / Signature Telephone No. ��l�o�s���� PERMIT FEE: $ 1 i I i I i t ~, i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations t 600 Washington Street Boston, MA 02111 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information a Please Print Legibly Name (Business/Organization/Individual): CA�-��IS 1 A J— y� Address: T^ — - City/State/Zip: 4rPhone #: Are you an employer? Check the appropriate box: Type of project(required): I.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2 1 am a sole proprietor or partner- listed on the attached sheet. E] Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its, officers have exercised their ]0.❑ Electrical repairs or additions required.] 3.El am a homeowner doing all work right of exemption per MGL 1 l.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other 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. lContractors that check this box must attached an additional sheet showing th.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. 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 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 c rtify un er t e. ins and penalties Pfperjury that the information provided above is true and correct. Si natur Date: Q 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#: Date...6�........e—............. TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING ACHUS This certifies that ........... .......... .......... ........... has permission to perform ..... ......... ............................ wiring in the building of ..........TRe�sl...... at......0 Z�...... ............�... North Andover,Mass. Fee�.. ..40 C";) t.......... Lic.No. .7 Check # 2-!2 �Ec.EcrxtcAt.MpEcTiA U Commonwealth of Massachusetts Official Use Only U9 Department of Fire services Permit No. `f~ BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07) (leaveblank 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: 1 ?- 7 7 — 0,f City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention tip orm the electrical work described below. Location(Street&Number) �j ( Owner or Tenant r, Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No PurPurpose of Buildin /�i � ' Utility Authorization No. &Q(Check Appropriate Box/) P g_ f7) Ft^1"I 19 /` Existing Service Amps Volis Overhead 1� ❑ Undgrd No.of Meters New Service � Amps It IO /&PvVolts Overhead ❑ Undgrdyl No.of Meters Number of Feeders and Ampacity I Z 40 Ayv(,yfl-.:t:> Location and Nature of Proposed Electrical Work. t Completion o the folloud table may be waivedhy the Inspector of Wires. r No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans NO• °f Total Transformers VVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- o.o mergency rg g d. rnd. ❑ Bette Units — No.of Receptacle Outlets No.of Oil Bu�rn_r_rs 7-,E ALARMS ido of%ones No.of Switches No.of Gas Burners f Detection and Initiatin Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alertine Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of No.of Devices or Equivalent No.of Heaters Data Wiring: Si Dns Ballasts . No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Te'ecommumcations Wiring: ` OTHER: No.of Devices or Equivalent s 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: P�-Z2-06 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: S�� --T-D,(T- LIC.NO.: Licensee. DSignature (If applicable, enter"exem t"in the license nu bei line.) LIC.NO.: L, tlk� Address: dd M G.L c. 147,,.7�61Msecun'ty work requires De a 1 d`j� Y Bus.Tel.No.: Alt.Tel.No.: & i q p nt of Public Safety S License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the Iiability insurance coverage normally required by law.AMY signature b low,I hereby waive this requirement. I am the(check one) ❑owner ❑ owner's agent. Owner/Agent Signature 1� e ephone No. PERMIT FEE. $ i r r _. r Ck . - :1 � _ i R a . -rW . .......-.. - C.� �� / J G% � %vv� ��' lD �/ I/ G� YY ✓ , I 1 I a J The Commonwealth of Massachusetts ki ! Department of.industrial Accidents Office of Investigations 600 R,ashington Street Boston, MA 02111 {j www.mass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A�Pficant Information Please Print Legibly Name(Business/Organization/individual): \J,9 bu G'/fi Address: City/State/Zip: l/e-/`c ( - p2 C�� Phone#: . [o f 2 5�l5 S ZS Are you an employer?Check the appropriate box: 1.ElI am a employer with 4. ❑ I am a general contractor and I Type of project(required): ,,�`employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 5A I am.a.sole proprietor or partner_ listed on the attached sheet t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demoliti.on working for me.in any capacity. workers' comp.insurance. g, ❑ Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.E3 Electrical repairs or additions 3.❑ i am a homeowner doing all work right of exemption per MGG 11.❑ Plumbing repairs or additions myself.[No•worke'rs'comp. c. 1.52, §1(4),and we have no 12.❑ Roof repairsinsurance required.]]t employees. [No workers' 13.❑Offer comp. insurance required.] *Any applicant that checks bo)e#l 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. 4contractom that check this box mustattached an additional sheet showing.the name of the sub-contractor;and their woke.=,c,,,,p,policy ir:5 rston. lam an employer that is providing workers'compewation insurance for aW employees: Below is the policy and job site information. Insurance Company Name: Policy 9 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 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 ce y under th p 'ns penalties of perjury that the information provided above is true and correct Si lure: Date: — Q Phone 1 �/5 3 Z ��- Offtcial 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 InspectEPiumbingctor 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 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, MGG chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into w ey contract for the perfornarim of public work mitil.acceptable evidence of c -,-.ipliance witl,'J e iltisurance 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 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 numberlisted below. Self-insured companies should enter their self-insurance Iicense number on the*appropriate tine. 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 indicatingcurrent 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 bum leaves etc.)said persm is NOT required to complete this affidavit The Office of Investigptions 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, MA 02111 Tel. #617-72.7-4900 ext 406 or 1-8.77-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia Date..4.'`�:.e9 -7 .; NORTII TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �,SSACMUSE� This certifies that ........... . .. ........................ ............................................... has permission to perform ......1.7.� .0 .`.1... , � ,................... wiring in the building of....... . ....................................... ............................. 4,lei(1FAe-,v- 41,eZ D,f 7- at at......Z I?.... ..............PLiEc-rin.- .North Andover,Mass. NSPECTOR /....... rFee. P ..'........ Lic.No. 3r......... � Check # A 7438 Commonwealth of Massachusetts Official Use Only Permit N Department of Fire Services rmo. 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: j — o 7 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) d Owner or Tenant S Telephone No. /�6(6 rPs- Owner's Address `e' QS-C �d J, if Is this permit in conjunction with a building permit? Yes © No ❑ (Check Appropriate Box)) Purpose of Building 1-1.4 A/6!C2 Utility Authorization No. 6 y 2 Z77 Existing Service Amps M / Volts Ovelead'❑ Undgrd No.of Meters New Service2-w— Amps `! 6 xvolts Overh ad ❑ Undgr No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: v cam' t Completion of the followin table may be waived by the or of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of ota Transformers No. of Luminaire Outlets No.of Hot Tubs Generators V No. of Luminaires Swimming Pool Above ❑ Wr ❑ o.o Emergency Lighting rnd. Batter Units No.of Receptacle Outlets 2O No.of Oil Burners FIRE ALARMS No.of Zones No. of SwitchesNo.of Gas Burners o.o Detection an Initiating Devices No. of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Num er Tons No.o el - ontamed Totals: Detectio lertin Devices No.of Dishwashers Space/Area Heating KWLoca Municipal ❑ Other Connection 7/7 No. of Dryers Heating Appliances Security Systems: No. o Water No.of Devices or Equivalent Heaters KW® NO'° No.o Data Wiring: Signs Balla t No.of Devices or E uivalen No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:Z2�No.of Devices or E uiva OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Valu of lectri 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 ex ' ited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHE (Specify:) I certify,under tfi ai s and a aIt' oT f per'ury,tfeat t e informa ' t/lis a I* ation is true and complete FIRM NAME: LIC. NO. Licensee: Signature LIC. NO.: (Ifapplicable,_enter " xe t"in he licen a number lin Bus.Tel. No.: Address: r ( 8 Alt. Tel. No.:. _ *Per M.G.L c.-147, s. 57-6y, security work requires Department of Public Safety"S" Li ense: Lic.No." ' OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the liability in prance coverage normally required by law. my sig re below, I hereby waive this requirement. 1 am the(check one)` owner E] owner's agent. Owner/Agent Signature Telephone No. �.7PERMIT FEE: $ Commonwealth of Massachusetts officialU-s�e�on1ly Department of Fire Services Permit No. p Occupancy and Fee Checked /o& BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) S�APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 l� r�;ASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1 — Q 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 S Telephone No. 17leas Owner's Address �' �l �&,1 10 /1yf 'e kQ X f 01dJ G, 1.26 Is this permit in conjunction with a building permit? Yes © No ❑ . (Check Appropriate priate Box) Purpose of Building ��, L—/L Utility Authorization No. 36 Existing Service Amps M / Volts Overhead ❑ Undgrd No.of Meters New Service Amps 6! d Volts" Overh ad ❑ Undgr No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: vf- Completion ofthefollowing able may be waived by th or of Wires. No.of Recessed Luminaires No.of Ceil: Tr Susp.(Paddle)Fans o ota Transformers K3A4i No.of Luminaire Outlets No.of Hot Tubs Generators V No.of Luminaires Swimming Pool bove ❑ In ❑ o.o mergency �g mg rnd. r- Batter Units No.of Receptacle Outlets ® No.of Oil Burners FIRE ALARMS No.of Zones A ' No.of Switches No.of Gas Burners No.o Detection an t Initiating Devices No.of Ranges No.of Air Cond. Tota No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump I Number I.Tons No.o el - ontamed Totals: Detectio lerting Devices Q No.of Dishwashers Space/Area Heating KW Loca Municipal ❑ Other Connection No.of Dryers Heating Appliances Security Systems: No.of Devices or Equivalent No.of Water KW No.of No.o Data Wiring: Heaters © Signs Balla t No.of Devices or E uivalen No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wines. Estimated Value of lectri 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,andhas ex ' ited proof of same to the permit issuing office. CHECK ONE: INSURANCE F1BOND ❑ OTHE (Specify:) I certify,under tle ai s and a allies of per'ury,that t e informa ' this a tication is rue and complete FIRM NAME: LIC. NO. Licensee: Signature MAO LIC. NO.: f (/f applicable,.enter " xe t"in e licen e number lin Bus.Tel. No.: Address: ( d Alt.Tel. No.: *Per M.G.L c. 147,s. 57-6y, security work requires Department of Public Safety "S" Li ense: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability in urance coverage normally required by law. my sig re below, I hereby waive this requirement. I am the(check one)' owner [I owner's agent. Owner/Agent ,' U� � PERMIT FEE: $ fo2.i—.°' Signature Telephone No. 7 01 5 1 I 1 I i - � U i i I 1 � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 y s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: 6217 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ am a employer with 4. ElI am a general contractor and I 6. E] New construction employees(full and/or part-time).* have hired the sub-contractors shipam a sole proprietor or partner- listed on the attached sheet. # ❑ Remodeling and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑ Electrical repairs or additions required.] 3.❑ I 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.❑ Roof repairs insurance required.] fi employees. [No workers' 13.0 Other 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. *.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: 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 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 herebyZ;n� ins d penalties of p rjury that the information provided above is true and correct. Si nature: Date: — o Phone#• &_L �� 5 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#: Date........... ...... y..... NORT►, °f,"`°;•�"� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �,ss^CMUSEt This certifies that � r, has permission to perform ...... �'... ...................... wiring in the building of . D U...� ..fit.. v tt -` ....... North Andover,Mass. Fee..... ....... Lic.No../.7.-1,3.51 ............ ...... . 3CM E CTRICAL NSP C 'Check # 10822 Commonwealth of Massachusetts Official Use Only Permit No. �lpe Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 ri (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: / lldL 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&�72�4 Y U 51/ 7 A,/ 41/6- Owner or Tenant Telephon o. Owner's Address Z-1 1 ey �2 / a 01 Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building COk- fti C/A-4— Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: '// Completion o 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- ❑ o.o Emergency Lighting rnd. rnd. Satter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALAN o, of Zones No.of Switches No.of Gas Burners No.of Initiating and Devices Tot No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Dis osers Heat Pump Number Tons KW_ No.of Self-Contained p Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal El Other P g Connection No.of Dryers Heating Appliances KW Security Systems:X Y No.of Devices or Equivalent No.of WaterKW No.of No.of Data Wiring: Heaters Signs Ballasts 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: god (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 ams andenaltt�s o perjury,that the information on this application is true and complete. FIRM NAME: . I 6?Zr C6 LIC.NO.: 1,5P1311-11 Licensee: ST�� 191,,57E-5T7 Signature 01 LIC.NO.: E3�13rj (If applicable,e r "exe pt"in th a nu r line. / Bus.Tel.No.: 617 goe Address: 0 �"Y 714 221 �1 /1'24. 0 r9l;o Alt.Tel.No.: *Per M.G.L c. 147,s. 57-61,security work requires Department 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 PERMIT FEE: $ Signature Telephone No. y f t �►��+(L'���j'.tAf'��et�'^(l�Q+3��1��J�T,''��I�'®pq.�ij.]�j �('1/'�'�•� _ .11.R1Lll�..0.►-.r. .t3#L(.11gF7.R.L1�.,1,.11'.0 - .. ._ s. a •.�_ ' ��sseu�-�[ �� J'�+'aile�•-•[ � �e-xuspectzort�'et�uixet7($�OAO)�( � �ns,�ectozs'�apame�ats: " ocappeefoxs5 iszgnafuze-m kultials) Date Xasse -- +aite$--j :€��nspecfZo� euixe�($ O.DO)- [ XuVactorls'col enfs; (!'xispectors'Oignahwo~n xnzfials) Slate S.TINDA+R CJRODND 3iQ'S°1ROCTION: 3.'asseal•-j � l;+'a�IetT--j � �te��.sp eetzonaea�razetl(,��O.DO)~[ � )ns,pectors'coxum.ents: , (lnspecfoxs'signatu -3.obftials) Pate . A.t E C.YAM`-D l�l"M a±ON's CP 1 I . NAME assec�--[ � �+`aftecl--j � ►�e-xnspectionxequiretl($50.DD)~( � ' Ispectbrs'eo7mweifs: f (Iiosectozs',�zglzatuxe~Jioinifials) )late ;sed-[ azfer [ )- 'ReInspectzon�eDuizecl($50.D0)~[ - �eetoxs'cozitxnerifs: _ • • S Vit,�s�ectoxs' 9zgnature no 5n fials) date ' '-t,1rl't��d��+ ,sb'GtrT*Jl'RTi�'�i7f7:fi�rti arl'rr�r A•�1'f►'tf'�Tr'7�ArD'1�7`�r�rTr�'r�i rrT�T!IS'D_'Fig.d '7f'G��t'A!'di'r74'"P1Fi'.+T��'firgx.4�'i�1'd�T�* V The Commonwealth of Massachusetts , - Department oflndustriglAccidents Office of Investigations 600 Washington Street .Boston,MA 02111 www.massgov/ilia Worker' Compensation Insurance Affidavit:Builders/Contractor6/Electricians/Plumbers Applicant Information GG Please Print Legibly Name(Business/Organiization/Individual): �i /7 6E'crx�� Address: / S� ZUGU.t/SEn,,,,,0 City/State/Zip:_ ,&k,0,,6Q�, /lf}• ole /Phone it: Are yo n employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 4. ❑ I am a general contractor and I ' 6. F1 New construction employees(full and/or part-time)* have Hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.x 7• Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working forme in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.[]Electrical repairs or additions required.] officers have exercised their 3111 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.❑Roof repairs insurance required.]i employees.[No workers' 13.❑Other comp.insurance required.] "Any applicant that checks box#1 must also fill out the section be16w showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they gie 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 showingthe name ofthe sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insuranceformy employees Below is thepnlicy andjob site information. Insurance Company Name% hl/el Policy#or Self-ins.Lic.#: ExpirationDate: Job Site Address: . �192Z �,S277DIII AV& city/state/zip: Attach a copy of the workers'compensation policy ileclaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o.152 can lead to the imposition of criminal penalties of a flue up to$1,500.00 and/or one-year imprisonment,as well as civilpenalties in the form of a STO •WORK ORDER and a fine dup to$250.00 a 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 certi rtheAl_ngandpenaltl ofperjury that the information provided above is true and correct. - Signature: Date: Phone#: �� 9&1 rOther only. Do not write in this area,to be completed by city or town official. n: _ Permit/License# hority(circle one): health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector - - - son: Phone#: t -r Information and Instructions . . Massachusetts General Laws cha Pursuant to this statute,an empter 152 requires all employers to provide workers'compensation for their employees. ployee 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 numbers)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. Iran 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 yl applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a homeowner 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 shquld you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho GQn onweal&of Mmarlausetts - Dapar4ment ofJndustdal.A,ccndonts Oflee of Investigations • 60(k�ashingtoaa.Street Boston,MA,02111 Tei,#617-727-4900 oxt 406 or 1-877,7MASSAFE Revised 5-26-05 Bax#617"727"7749 r rin Sowtions,LLC Bu -' ilding and Engineering Engineers - Project Managers a Designers d Airp ort Consultants Building Code an Subsidiary of New England Design and Building Technologies,Inc. 16% STRUCTURAL FINAL AFFIDAVIT September 22,2009 Don° ianquitlo owner 492 Sutten Street North Andover, MA. D� Ref. • Building Permit # 7-5-200 � Erection of Two Aircraft Hangars At North Ramp w of North Andover To the Building Commissioner: oWt1 I ox my auth°xized representative, have inspected the work associate I Nazeiih R. Hammouxi certify that , at:Lawrence Municipal Airport the work has been done in accord of the with the project knowledge,information and belief, with the provisions and that to the best of my the Building Department and conforms Permit and plans approved by Massachusetts State Building Code and all other permanent laws and ordinances. -\\OF MA,,� S.REG.No. 36786 ENG EER— � eerie Solutions LLC. / NArE'� - ` ' n land Buildin &En HAMlvrioolll,l�,t=:: �� N {'r11tiP.i, MPANYs Park Suite 1725-121 Woburn MA 01801 5161.7 400 W.Commie IJp.;5k31f1f jai ADDRESS goo-433-4410 ]0 PHONE *' June.6 and June 20, 2009 all structural members w) Inspection Dates: 2009 structural framing installed, connected to the structural May 169 2009, May 27' ulv 25 roof and walls complete and promptly idy 11 and J conforms to structural erecrion drawings y g Properly installed. J 2009 final walk through overall building Y members. September 19, R&M Building Systems. ,�af� �•qGu�ut26�P�and made oath that the above statement � ' amed "�'J 1�Then personally appeared the above-n by is true. Before me, l i My Corr..'niss�.on ex r'.res ...�.._ s Park, Suite 1725-121,Woburn, MA 01801 i 4d �N Cuff ce 7 81.245-6615 Fax: 781-246-3040 E-Mail: CJMartinPE Bld Tech.cOrn E-Mail: Nazeih Bld Tech.91for All" "Integrity Is Nonnegotiable and Resp CLIA N 1774 roe � S