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Home My WebLink AboutMiscellaneous - 371 Blue Ridge RoadDate ..... /1....'.....<..—• TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... # ..... . ............................. has permission to perform ....... l�.. (71. 2. X' &.W. ........................................ wiring in the building of .............. ff'.0tK.( . ................................................ at ........ North Andover, ass. ... ... ... ..... ... ... ....... Fee .3::F�.. Lic. NO. ........ .. ......... ELECTRICAL INS PE, R Check# 10463 R Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. �V y Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.]/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 27 CMR 12.00 �\ (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the InsActd of Wires: By this application the undersigned gives notice of his or her intention to erform/t�he electrical work described below. �Q Location (Street & Number) .3 1 % Clue kt U /< c a 11/ Owner or Tenant t k e f Da r- , 4,e 671 1 Owner's Address sa m -e Is this permit in conjunction with a building permit? Yes L Purpose of Building o/ ,.,e///!? C Telephone No.! 7fJ —07 Sof' / X39 No ❑ (Check Appropriate Box) Utility Authorization No. Existing Service aC>O Amps (dam /:ZYb Volts Overhead ❑ New Service Amps / Volts Overhead ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: o/ �vPra0-0 1',n _ CIrlu,f. "1 ac Undgrd Eg-- No. of Meters Undgrd ❑ No. of Meters tGct/C CivCol/" Rn ?n .rte c/✓� r%�/e C_ nPAA' m 1[/!'2✓ -,& Feil` I Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans TransTotal Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- 11 rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection and Initiating Devices No. of Ranges No. of Air Cond. otal Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW No. o Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP a ecommumcations Wiring: No. of Devices or Equivalent IOTH ER: Attach additional detail if desired, or as required by the Inspector of Win Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue un] the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. Th undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [" BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: E' r G! Signature LIC. NO.: ) ?�� (Ifapplicable, enter exempt" i jhe lice a number 'ne.J Bus. Tel. No.; 7 / Address: (J' 14 U 0 19 `ry Alt. Tel. No.: 2 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage norn required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's Owner/Agent PERMIT FEE. $ Signature Telephone No. A The Commonwealth of Massachusetts Department oflntdustria[Accitdents Office ofInvestigations' 600 Washington Street s� Boston, MA 02111 www.massgovldia Workers' Compensation Insurance Affidavit: Builders/ContractorslElectricians/Plumbers )]%cant Informafinn Name (Business/Organization/Individual)): Address: City/State/Zip: /� 4--t-4, �iI �! Zjj �`�y Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general ` contractor and I 2. Eemployees (full and/or part-time).* have hired the sub -contractors l am a sole proprietor or partner- listed on the attached sheget. ? ship and have no employees These sub -contractors have working forme in any capacity, [No workers' comp. insurance workers' comp, insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing officers have exercised their 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. O,&modeling 8. ❑ Demblition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other *Any applicant that checks box Homeowners who submit #1 must also fill out the section below showing their workers' compensation policy information. I this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and 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. Lie. #: 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. Ido Hereby certify nder the pat a ies ofperjury that the information provided above is true and correct. Si nature: / Date: l /G l/ ?hone #: �- " C� �� — 3 ;74' Official use only. Do not Write in this area, to be completed by city or town offrcial City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other Contact Person: Phone #: P 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 personin 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 apartinents 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 Iicense 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 insuranc6 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) andphone number(s) along with their certificates) 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 retained 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. PIease 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 (ifnecessary) 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 NOTrequked 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 Cormionwealtla of Ar4assaclat?setis Department of Industrial Accidents Office of Investigations 600 Washington Street Boston; MA, 02111, Tel. # 617-7.27-4900 ext 406 ox 1-877-MASS,AFE Revised 5-26-05 Fax # 617,727-7749 www.mass.gov7dia. 99u2 Date.... 2- -. ZI TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............. ? ...... .... .. has permission to perform ......... /'r.- wiring in the building of ................ f�7.,/� z ................................................ i at ....... (I :, E. la i. 1 .... Xf) ......... . North Andovei, Mass. 7 Fee ..... � Lic. No.37�/J--75...—� .......... ELECTRICAL INSPECTOR Check # /42Cd W l� h COMMOn wealth ®f Massachusetts Department ®f Fere Services BOARD OF FIRE PREVENTION REGULATIONS Otucial Use Only Permit No. �P?, Occupancy and Fee Checked _ Lev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL AU work to be performed in accordance with the Massachusetts Electrical Code C), 5 7 CN R 12.00 �®RK (PLE,MEPRMTININKORTYPEALLINFO � �� City or Town of: TION) Date: By this application the undersi ed gives no ' e of his or her intal Zentionto perforTo m the electrical w e -Inspector of described Belo Location (Street �& Number) w. Owner or Tenant /? .4 V . I — , „ y Owner's Address Is this permit in conjunction with a building permit? Purpose of Building / / f11^/G Existing Service Amps ` AW its Newer Ce Amps _ /--Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: of Recessed Luminaires [No. f Luminaire Outlets f Luminaires f Receptacle Outlets Switches Ranges Waste Disposers DishwashersDryersWater KW Heaters No. Hydromassage Bathtubs OTHER: ,iw Ivo *J BJA)G PERMIT ff Utility Authorization No. Overhead ❑ Undgrd1 No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Completion of the followl,, No. of Ceil: Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Above [] �- i=rnd ❑ No. of OR Burners VO. of Gas Burners Vo. of Air Cond. Too- le e/Area Heating KW sting Appliances KW of No. of Signs Ballasts of Motors Total HP /A/ table may be waived by the Inspector of Wires Ivo. ox Total. Transformers KyA Generators KVA. IRE ALARMS INo. of Zones fo. of Defection and Initiating Devices o. of Alerting Devices o. of Self -Contained etection/Alerting Devices )cal ❑ Municipal Connertinn ❑ Other No. of Devices or Data Wiring: No. of Devices or Telecommunications No. of Devices nr a Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: Work to Start: In(When required by municipal policy.) Inspections to be requested in accordance with NEC Rule 10, and upon completion. Il\TSUItANCE COVERAGE: Unless waived by the owner, no permit for the performanc the licensee provides proof of liability insurance e of electrical work may issue unless 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:) Icerlry, render thepains andpenalties ofperjury, that telae information on this application is true and conpplet� FIRM NAME: 4E A11, e Licensee: L/4ij�� /I, C/�j�/,� Signature LIC. NO. - � (Ifapplicable, enter `exempt" in the license number line. LIC. NO.: Address: /% Lam'(/, fT �f'T. /J/j)kwe A if, Bus. Tel. No. :��2f 49Ga *Per M.G.L c 147, s 57-61, security work requires Department of Pubhc Safety "S" Licen Alt. LIC.. lvt0.: OW1vER'S INSURANCE WAVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. 13y my signature below, I hereby waive this requirement. I am the (check one) El ❑ owner's agent. Owner/Agent g Signature Telephone No. pF RMIT FEE: $ ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL I. ROUGH INSPECTION: Passed — [ ] Failed — [ j Re -inspection required ($50.00) - [ j .Inspectors' comments: (Inspectors' Signature - no initials) Date 2. FINAL INSPECTION: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 3. UNDER GROUND INSPECTION: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 4. INSPECTION — SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 5. INSPECTION - OTHER: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. .IV The Commonwealth ofMassachusetts Department of Xnclustrial.Acculents Office oflnvestigations 600 Washington, Street Boston, MA 02111 www.mass:gov1dia Workers, Compensation InsuranveAffidavit: Builders/Contractors[ElectriciansfJPlumhers mHeanUmformation 1PjnaL*01 Prin+ T.PCY;jkj1 NaM8(B.usiness/Organizatiou/Individual): � ,�C� �� G/�I/�✓/ r Address: I,�? 3r, City/State/Zip: Phone #: Axe you an employer? Check the appropriate box: Type ofproject (required): 1. �I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑ New construction employees (full and/orpart time).= 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. t 7. ❑ Remodeling . ship and have no employees These sub -contractors have S. [❑ Demolition working for me is any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We area corporation and its 9. ❑ Building addition required.] officers have exercised their 10.❑ Electrical repairs or additions 311. 1 am a homeowner doing all work right of exemption per MGL 1111 Plumbing repairs or additions myself. [No workers' comp. c.152, § 1(4), and we have no 12. [ I Roofrepairs insurance required.] i employees. [No workers' 1311 other comp. insurance required.] 'Any applicant that checks box#1 must also flI out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that isproviding workers' compensation ' suranceformy employees Below is thepolicy andjob site information. Insurance Company Name:ZIZ4�;Gl_ Policy # or Self -ins. Lic. #: �7�(Expiration Date: rob Site Address 111 �LZ�r A`C/ 4,,e_, 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 dkA the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations thnsurance coverage verification. I do Zier eb ce> ti net th ins andpenalties ofperjury that the information provided abo els t e and con act. Siafore• Date: 1 ;7 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): I. Board ofHealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other C ontactPerson: Phone 90�� Date. .A -e- TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING cc This certifies that �.C..�!'� � {"'.`�...�.�` 1`^ .. !.� .. has permission to perform plumbing in the buildings of ..�.�-fit... �.� ! ................ at ..31.E . •��'?..d.S,Q,,..V�J� :...... , North Andover, Mass. Fee. D7 P.Lic. No... �.�T.1.6 ......, �'... PLUMBING INSPECTOR Check # 16U Fowl MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) = W 6 r �� i�N�(l�� , Mass. Date I it 19 W d City, Town Permit # Building Owner's AT: Location S�k�� d 5� Name- Type ame P. Type of Occupancy: S' New ❑ Renovation ❑ Replacement FIXTURES Plans Submitted Yes_ ❑ No ❑ (Print or Type) C Installing Company Name M t n -p–f n -e v �+ Address ___I a. S ?,Lr k S4 - Check One: ❑ Corp. ❑P rtnership — Firm/ Company Business Telephone Name of Licensed Plumber or Gasfitter Certificate 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 Massachusetts State Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owner/ Agent / I have a current liability insurance policy to include completed operations coverage. By Title City/ Town APPROVED (OFFICE USE ONLY) FORM 1240 1-1&W 1iOBBS 8 WARREN TM to of Licensed Plu er ! ( � Type of PlurM iLicense aster ElJourneyman License Number 37'-5-0 IMUMMENEENEENEENNE mom AMENNOMMMM; (Print or Type) C Installing Company Name M t n -p–f n -e v �+ Address ___I a. S ?,Lr k S4 - Check One: ❑ Corp. ❑P rtnership — Firm/ Company Business Telephone Name of Licensed Plumber or Gasfitter Certificate 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 Massachusetts State Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owner/ Agent / I have a current liability insurance policy to include completed operations coverage. By Title City/ Town APPROVED (OFFICE USE ONLY) FORM 1240 1-1&W 1iOBBS 8 WARREN TM to of Licensed Plu er ! ( � Type of PlurM iLicense aster ElJourneyman License Number 37'-5-0 z O FE N V m A O m e 7 r c a m 9 r A s O z O N c r d_ z 0 f z O In m m N m r O 91 O N O n m c N m O z r r - COMM0NW ALYF OF MKS -8A 14(iSE LICENSED AS A MASTEOV R LU `R R ISSUES THE ABOVE LICENSE TO: ` ! JAMES.T MCINERNEY 128 PARK ST ,� �_ NORTH READING MA 01864-540 12716 05/01/12 78 733 L:n.enZOt UI EXPIRAT ON DATE SERIAL O. - i 7764 Date. 71.: 4 -.l I ....... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that. has permission for gas installation AZ- (447t"-. .. a... 4%C -A � 4_ in the buildings of .. ... A ...................... at North Andover, Mass. Fee.- . . (-.0. Lic. No. 6 ... ...i � C....,/ 4.L,.... . GASINSPECTOR Check #1 O'K— (Print or Type) NdC4 QN�U��f- Mass City, Town Buildin AT: Lccat on s I`��w2 TI -06 New ❑ Renovation ❑ Plans Submitted Yes ❑ No ❑ Date I l 9 I f 19 Permit k Owner's Name} - Type of Occupancy: 5 �� a✓�1 Replacement U ( Pnnt or Typc) M�.I Chcck Onc Certificate Install ng Company Namc 1 ��Chefn-e`1 T � 64 ❑ Corp. Address �a$ �a""k St ❑ Parincrship /bacA f?szc�div�� /Vt� olg�y 2 Firm/Company Business Telephone �� 2" �� aa �' Namc of Licrnscd Plumber or Gasfitter AA ,/ I hereby cen fy that all of the details and information I have submined (or entered) in above application arc true and accurate to the bat of my rnowtcagc and that all plumbing Work and insullations performed undcr Pcrmit issued for this ►ppliution will be in compliancc with all peruncnt yovts ons of the M►swchusctu Sutc Gas Code and Chapter 142 of the Genoa[ Laws. I hs�c nformcd the owner or his agent that I do not have liability insunna including completed operations eovcrage. Sgtiiurt or 0�0 AKe1 . I havc a currcnl liability insunna policy to include completed operations coverage. r By . Titic City/Town APPROVED (OFFICE USE ONLY) TYPE LICENSE: fr• ��«�` �r��a►iaaaat� C - _ ,A, __o .1I-1.. —, '000 * •_.` ,f /► a h 0 � urc of Licensed 1.11 Plumber or Gasfittcr ❑ Gasfittcr c ?__M aster ❑ Journeyman License Numbcr C - _ ,A, __o .1I-1.. —, '000 * •_.` ,f /► a h 0