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HomeMy WebLinkAboutMiscellaneous - 25 Redgate LaneN d e;L aNanrN � ` s CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 186 (9/7/2007) Date: December 4. 2008 THIS CERTIFIES THAT THE BUILDING LOCATED ON 25 Redgate Lane MAY BE OCCUPIED AS Single Family Dwelling IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Whispering Pine Realty Trust 89 Belmont Street North Andover MA 01845 .,�O�a- &,U� Building Inspector 1p a m a. w ul U) W w W. w w cn O C2 c C3 C3 C.3 L) CL O. lu- C) CD U)= E CD 0d it 0- rA V CO2 0 co ro- CD =o 0 cf) N \Aj Cc ta, CA —co y Cj 0 L2 Cf) '0 LL, "4 Cc* V) m a. w ul U) W w W. w w cn O C2 c C3 C3 C.3 L) CL O. A C) CD U)= E CD 0d it 0- rA V CO2 0 co to CD =o ca Cc CA E Cc* C-7 CCL 0 CD CD coo O U3 C6—C= CL.= ' .2 CCjD CO = LU u C3 cm 0 to !E = y_ U3 co0 = CL � L Cc m a. w ul U) W w W. w w cn w. APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION Building .Permit # ADDRESS/LOCATION OF PROPERTY: ��� 6 Map 9 Parcel Q �� Lot Number W SUBDIVISION -Re°�� DATE REQUESTED FILED/READY FOR INSPECTION — / — o CLOSING DATE ON PROPERTY: FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE- INSPECTION FEE OF TWENTY DOLLARS $20.00) WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES_ Permit Issued to: Address ---?4 SIGNED CONSERVATION PLANNING DPW - WATER METER I SEWER/WATER CONNECTION NOTE DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW Signature File: Application for OC form revised Jan 2007 Date... . `!....r... .... . TOWN OF NORTH,AIVDOVER PERMIT FOR GA INSTALLATION This certifies that..... ':..'.::..... 'A* ... .... has permission for gas installation .:..-.�..-�� ................. . p in the buildings of .:.. s,- c - �� ' ................. . at .1� .... ... , , .. , , ., North Andover, Mass. Few�'7 .Lic. No .� ,: � .......... �j GAS INSPX TOR Check # D " 701! 0 I 5M MASSACHUSETTS UNIFORM APPLICATON FOR PERMrr TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations :Z�: 1\ SCJ"ic L A h r } 1 n A:> Owner's Name New ❑ Renovation Replacement Plans Submitted Dateyo u "l �,O l Permit # Amount $ (Print or type)�� Check one: Certificate Installing Company J� Name L h U t/ n-� p� 11 [] Corp. Address J 3 C3 16C K 0 Vi -V, y 1 ti Kis � to M I-+ El Partner. Business Telephone ® Fum/Co. Name of Licensed Plumber or Gas Fitter ,J D � h «O V- m INSURANCE COVERAGE Check o I have a current liability Insurance policy or it's substantial equivalent. Yes No If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Er Other type of indemnity 1:1 Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 1:1 Agent 0 I hereby certify that all of the details and information I have submitted entered) in above a hcation are true and accurate to the best of my knowledge and that all plumbing work and installatio per ed d r Permit ed for this application will be in compliance with all pertinent provisions of the Massachusetts S ate G de Chapter of the General Laws. own (OFFICE USE ONLY) Signbhe of Licensed Plumber Or Gas Fi� Plumber � a Gas Fitter Icense Number Master Journeyman `IS J e- � w w w a p Ow ORZ F v� CG z U W xa, v� W Fa W OF U F z Q �" W C W F V x F4 F zz F C% ppb > w z .aG Fm W � W > W Z d d O W W F m o x w w 3 0 Q v O x > a O o F o SUB-BASEM ENT B A S E M ENT LST. FLOOR 2N4D. FLOGR -3.W D. FLOOR PH. FLOOR Q1 H. FLOOR 6TH. FLOOR 7 H. F L O O R 8TH. FLOOR (Print or type)�� Check one: Certificate Installing Company J� Name L h U t/ n-� p� 11 [] Corp. Address J 3 C3 16C K 0 Vi -V, y 1 ti Kis � to M I-+ El Partner. Business Telephone ® Fum/Co. Name of Licensed Plumber or Gas Fitter ,J D � h «O V- m INSURANCE COVERAGE Check o I have a current liability Insurance policy or it's substantial equivalent. Yes No If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Er Other type of indemnity 1:1 Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 1:1 Agent 0 I hereby certify that all of the details and information I have submitted entered) in above a hcation are true and accurate to the best of my knowledge and that all plumbing work and installatio per ed d r Permit ed for this application will be in compliance with all pertinent provisions of the Massachusetts S ate G de Chapter of the General Laws. own (OFFICE USE ONLY) Signbhe of Licensed Plumber Or Gas Fi� Plumber � a Gas Fitter Icense Number Master Journeyman `IS J e- The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA -02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate bog: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I rployees (full and/or part-time).* have hired the sub -contractors 2.& Iam a sole proprietor or partner- listed on the attached sheet. $ ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t -employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other r.ry a—ypucam mar ;.:.eci s. Dox;;; MUM also nu 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 hereby certiX"ndA4 the p ins and penalties of perjury that the information provided above is true and correct Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 11 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 t 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.4 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 apartrnents and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any. contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability.Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. . City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (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 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, MA 0.2111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 vvnwwmass.gov/dia Date ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............... klp-111141L, .... WIM& ........................... has permission to perform ...... .................................... R vo, wiring in the building of ................ee 5............................................... at ....... N rth Andover, Mass. Fee��e? ../ ......... Lic. No..?.. ... 2r--, ......... . . CTRICAL Check # 7797 Commonwealth of Massachusetts Official Use Only Permit No. / Department of Fire Services OP., Q Occupancy and Fee Checked V r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: l / -3/,02 City or Town of: NORTH ANDOVER To the InsprWires: 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 C �/� �d ,/ �7�/rr— Telephone No. Owner's Address t/ )s kl-T joi1 X/ )0 A"111.1 14// Is this permit in conjunction with a building permit? Yes, KJ No ❑ (Check Appropriate Box) Purpose of Building A/C t,✓ thm Utility Authorization No. _ Fw ;?, Gj Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service � Amps %O�v 1,)W Volts Overhead ❑ Undgrd (2— No. of Meters Number of Feeders and Ampacity x6 � /11v�� OL, Number . "/I Location and Nature of Proposed Electrical Work: �a,,c��/T� �jn�,„✓ �L. Completion of the.following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans NO. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ n- ❑ rnd. grnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Dis posers p Heat Pump Number Tons K o. o Se f- ontamed Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ un'cipal ❑ Other Connection No. of Dryers y Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW No. o No. of Data Wiring: Heaters 'Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications firing: No. of Devices or Equivalent OTHER: oAttach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: /DOyU- (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 N� BOND ❑ OTHER ❑ (Specify:) I certify, under th}e/pains and penalties of perjury, that the info oration on this application is true and complete. FIRM NAME: X,-1, -/ UA117.J j,f 1'.,'A -J1 ��o� /Zi.%9i✓ LIC. NO.: Licensee: _&6/,.. %YITi-� Signature LIC. NO.: 3 (If applicable nter "exempt" in the license number line.)_Bus. Tel. No.:..T7YJ _ Address: SV IIIJOYCAlt. Tel. No.: *Per M.G. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, 1 hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ 77 Signature Telephone No. Qz ,,- ©( !_ z -d9 A Am-e2 w� 4 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information { Please Print LeEibly Name (Business/Organization/individual):�t/��./ /./j�f'7�✓ Lel �f'i✓$ ''df ��( Address: V('. CU/ _ 4ve City/State/Zip: If �j�/�j,// Phone #: Are yo n employer? Check the appropriate box: 1. I am a employer with __jn7—- 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. P�New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #I 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: Z l 2 a Job Site Address: � /�Tof �'f� �/i/. City/State/Zip: /A/ 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 a of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. l/ t'3 d7 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 #: JAMES A.0VAY. P. E. 599 Canal Street Lawrence, MA 01840-1233 Richard Keller 4 Fosters Pond Road Andover, MA 01810 RT7.Beams 25 Red Gate Lane, North Andover To whom it may concern, Office: (978) 687-6350 Res: (978) 373-4395 January 24, 2008 I recently inspected the hose under construction at the above referenced address. I found that the structure was in accordance with the plans. My calculations further found that all beams are more than adequate. Should you have any questions please call me. Very truly yours, or James A. O'Day P.E.ozy' fi€� JAMS,NI ODAY 'c Date, b�rJ7.... TOWN OF NORTH ANDOVER .: PERMIT► FOR GAS INSTALLATION . 9 4 USEtS This certifies that...... ...........P/I. has permission for gas installation .... .............. in the buildings of . ! ?l �.... :. at f e ............. North Andover, Mass, �1 Fee/op,.... Lic. No..! C ...... ..... �. .....z.� ....... GAS INSPECTOR V Check #/c7 6265 MASSACHUSETTS UNN ORM APPLICATON FOR PERNII'T TO DO GAS FITTING (Type or print) Date 4Z-141�7 NORTH ANDOVER, MASSACHUSETTS Building Locations Permit # 4. Amount $ �,,� Owner's Name New U Renovation ❑ Replacement Plans Submitted (Print or type) Check one: Certificate Installing Company Name y -- -- 1:1 Corp. Address ❑ Partner. i Business a ep one 77 ` g -S `/2 R / ❑ Firm/Co. Name of Licensed Plumber�or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance' policy or it's substantial equivalent. Yes 13-- No❑ If you have checked Les, please indicate the type coverage by checking the appropriate box. 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I herehu rArtif, tho4 011 -f+1- I- a _d - --- --- -- .--- -- - - -•-- • I-- kV1 cmarnul In aoove appucation are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Cop andapter 14 of the (p�eneral Laws. /l % // A By. Title City/Town; I APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber �- 7 ❑ Gas Fitter License Number Taster 0 Journeyman 2 a w v�' c� zZ F o x J- Z E. GC7 < H Z F x W C w C ca'7 q�>'." Z W > Z4' r/� m Z O F z o x rQzl ° a > a a F o SU B-BASEM ENT .da BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR STH. FLOOR (Print or type) Check one: Certificate Installing Company Name y -- -- 1:1 Corp. Address ❑ Partner. i Business a ep one 77 ` g -S `/2 R / ❑ Firm/Co. Name of Licensed Plumber�or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance' policy or it's substantial equivalent. Yes 13-- No❑ If you have checked Les, please indicate the type coverage by checking the appropriate box. 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I herehu rArtif, tho4 011 -f+1- I- a _d - --- --- -- .--- -- - - -•-- • I-- kV1 cmarnul In aoove appucation are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Cop andapter 14 of the (p�eneral Laws. /l % // A By. Title City/Town; I APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber �- 7 ❑ Gas Fitter License Number Taster 0 Journeyman Date. 0RT:��o TOWN OF NORTH AN OVER 0 j • ' •• O PERMIT FOR PLU,4BING -1 CHU51 l ,/ ��j This certifies that .. A/ A `:.�.t. .. .�/.......... . �Lti�s has permission to perform ....... r.�.......... .............. r-' /w ll� plumbing in the buildings of ..........::...... ............ . �- ,North Andover, Mass. at .... � ,..... ' /:�.' Fee° J^..... Lic. No../.�..`/" ...... ... 1,.� ^-�..- -, ....... r�IUMBING INSPECTOR Check !/ � 5 � 7601 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location of Date D" Permit # 7 7 27', Amount New Renovation Replacement Plans Submitted Yes ❑ No ❑ (Print or type) ` Check one: Certificate Installing Company Name / ❑ Corp. Add r ❑ Partner. JIL Q 7 u mess Telephone J�aFIMVCG. Name of Licensed Plumber: Insurance Coverage: Indicate the typ of insurance coverage by checking the appropriate box: Liability insurance policy �' Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ 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 plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massa Zhu, State P umbin Codeap 142 of the General Laws. By: e : , 1, �OgnaLure of I-icensea Mumoer Title Type of Plumbing License City/Town icense um er Master [aJourneyman ElAPPROVED (OFFICE USE ONLY i • .J I i MM WN -07 0NMMMM.-----�---------------1 -t_� ,_MM© -.M. ------------M----- - mmmmmmmmm----------------■ !, n / * ' M-M.M-------M------------■ , # ' -----..-.m---------------■ 0 i.' ---t-------t------------ 1 lig.' --.---.-----------------� 1 t m,' --.--------.-----M-------E (Print or type) ` Check one: Certificate Installing Company Name / ❑ Corp. Add r ❑ Partner. JIL Q 7 u mess Telephone J�aFIMVCG. Name of Licensed Plumber: Insurance Coverage: Indicate the typ of insurance coverage by checking the appropriate box: Liability insurance policy �' Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ 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 plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massa Zhu, State P umbin Codeap 142 of the General Laws. By: e : , 1, �OgnaLure of I-icensea Mumoer Title Type of Plumbing License City/Town icense um er Master [aJourneyman ElAPPROVED (OFFICE USE ONLY Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING L�-�:c�..rt This certifies that ..._;............. ..........................'`�', ......,�...................... has permission to perform......................................................... wiring in the building of.. ?.........,-..................:..........:......h•a..1/.... at../ ....c '4:- .......... �................................ .... . North Andover, ass. .... Lic. No.AS cb . .............r. � ...... p ELECTRICAL INSPE R Check # , 7665 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date:T_��.- City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives noti of his or h intention to perform the electrical work described below. Location (Street &Number) . / � /`, d Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes No ❑ (Check Ap ropriate Boz) Purpose of Building , 5e k I,& i- -e Utility Authorization No. 70 t Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service 4- Amps J/CJ�Volts Overhead Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No, of Recessed Luminaires � 11 � No. of Ceil: Susp. (Paddle) Fans ware may ae warvea by the !ns ector of Wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o mergency Lighting BatteEyUnits No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Tonal No. of Alerting Devices No. of Waste Disposers eat Pump Totals: Number - 1.Tons "' KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers No. o Water Heaters KW Heating Appliances KW No. of No. of Signs Ballasts Security Systems:* No. of Devices or Equivalent Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail zf desired, or as required by the Inspector of Wires. Estimated Value of Electrical —Work: (When required by municipal policy.) Work to Start: �'� �t / Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE OVERAGE: 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 0 BOND ❑ OTHER ❑ (Specify:) I certify, under the ins an penalties of erjuryl that the i if, on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: Signature LIC. NO.: ;ILU (Ifapplica e, enter "exempt" in gre lic a number line.) Bus. Tel. No.• Address: 4 C GlFb4 Alt. Tel. No.: -q - *Per M.G.L c. 14;fl s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. T'� 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 a Signature Telephone No. PERMIT FEE: $�j�l The Commonwealth of Massachusetts k. ! Department of Industrial Accidents .. Office of Investigations E1C� iEli ! 600 Washington Street Boston, MA 02111 e'-; www.nxass.gov1dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: City/State/Zip: [�)�> S.. 4---,�V,: ,1 1/1/114 G C_, Phone #: I/ - 71 Are you an employer? Check the appropriate box: I ( I am a employer with 4. ❑ i am a general contractor and I employees(full and/or part-time).* 2. ❑ I am.a.sole proprietor or partner- have hired the sub -contractors listed on the attached sheet i ship and have no employees These sub -contractors have working for mein any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No -workers' comp, c. 1.52, § 1(4),' and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. [] Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.FRoof repairs 13.❑ Other -w AFF...... +mai �JwKzi oox it m mustalso m out the section below showing their workers' compensation policy information. t Homeownen 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 4M an employer that is providing workers' compensation insurance for HW employees: Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: �— ' G ' . L,,) —city/state/zip--L 4Gl0�C1� 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 cellounder t E pains and penalties of perjury that the information provided above is true and correct 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone #•