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HomeMy WebLinkAboutMiscellaneous - 429 Main Street �e�� �H i r� S�REQ`)'; i Date.. ........... TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING 6E A MUS This certifies that ........ ...... . ............. .......... . ............ has permission to perform wiring in the building of............. .. ... ................. . .......................................... at ......................... .............. 1�- .......... . ........Z., ,North Andover,Mass. . . il .Fee . ... .. ...... Lic.No . ............. . . ......... ELECTRICALINSP OR Check # 8930 ' Commonwealth of Massachusetts Official Use Only Department of FireServices Permit No. R?&O BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked �- [Rev. l/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR RIy 0 0WORK (PLEASE PRINT WINK OR TYPE ALL INFORMATIOl9 Date: City or Town of: NORTH ANDOVER By this application the undersi ed To the Inspector of Wires: gn gives notice of his or her intention to perform the electrical work described below. Location(Street&Numb11 er) � mA11 J V-. Owner or Tenant 1__T'�A Owner's Address t9 Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Buildingvl���/A) �-- Utility Authorization No. E3dsting 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: A-4-A n- <tv Gov Completion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of CeiL-Sus No.of Total . p.(Paddle)Fans No.of Luminaire Outlets KVA No.of Hot Tubs Transformers Generators KVA No.of Luminaires Swimming Pool Above�❑ In' ❑ o.o mergency ig g d• Batte Units No.of Receptacle Outlets No.of on Burgers FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o..of Detection and No.of No.of Air Cond. otal Ranges Initia kg Devices T Tons No,of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: __ _._._..._. _.....__..... Detection/Alerting No.of Dishwashers Space/Area Heating KWDevicesLocal❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Water )E No.of Devices or Equivalent Heaters No.of No.of signs Ballasts . Data Wiring: No.Hydromassage Bathtubs No.of Devices or Equivalent No.of Motors Total gp Telecommunications Wiring: j OTHER: No.of Devices or E i uivalent Attach additio Estimated Value of Electrical Work: nal detail tf desired, or as required by the Inspector of Wires. u (When required by municipalpolicy.) INSURANCE COVERAGE: Work to Start Inspections to be re requested m accordance with MEC Rule 10,and upon completion. Unless waived by the owner,no permit for the performance of electrical work may issue unless the Iicensee 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 ❑ (Spec I certify,under the pains a ') p nd penalties o erjury, that the information on this a 1" FIRM N' pp tcadon is true and complete AME: J,(.,v � W L 6 Licensee: IC.NO.: Signature (If applicable, enter"exempt'y' in�the license num a line.) LIC.NO.: Address: /' �j (y(,Y�Gc� Bus.Tel.No.: .S 0�— ,S`"/-yS7d Per M.G. 6 L c. 147,s. 57-61,security work requires Alt.Tel.No.: d3—f� 6 -g/ J tY q ires Dep t of Pu lic 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 waivethis requirement. I am the(check one) ❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ Q S�' �� m ,Y i r. -. �, � 3� ®� -��� �� �� �.-� d� , . , � � i. �, The Commonwealth of Mtrssachuse#s k- 1 Department of Industrial Accidents j I • ( Office of Investigations iM600 Nrashington Street Boston, MA 02111 www.n ass gov/dia . Workers',,Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lbly NaIne (Business/Organization/individual); Address: ���1 �t S City/State/Zip: 1-2bIlL_ON Phone#: . Are you an employer?Check.the appropriate box: I.❑ I a employer with 4. Type of pr"rn (required): ❑ 1 am a general contractor and I ployees(full and/or part-time),* have hired the stub-contractors 6 ❑Newtruction 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 mei' any capacity. workers' comp,insurance. [No workers'comp.. insurance 5. 9•. (]Building addition ❑ We are a corporation and ifs required.] officers have exercised their 10.F7 Electrical repairs or additions 3.❑ I am s homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No•work=' 'comp. c. 1.52, §I(4),'and we have no 12. Roof insurance required.].t -employees. ❑ repairs [No workers' comp, insurance required..] 13.(].Other *Any applicant that checks bob tf I must also fill out the section below showing their workers'compensation pot icy information r 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.polfcy inforn, on. I am an employer that is.providtng:workers'compensation insurance,for my.employees: Below is the inforpolicy msd job site mation. 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 tip 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 y under the Pains and p enalies of !mthat the information provided above is true and coned Si Phone#: ------------------ FB�aeal*tyb only. Do not write in oris area,to be completed by.city or town o�ciaL n: Permit/License# hority(circle one): -71 Health Z Building Department 3.City/Town Clerk 4.Electrical Inspector 5. PlumbEns ] son: 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 j 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 I52, §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 toyour 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 requiredto 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 app-Iication 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,pleancall the Department at the nurnber.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 abd 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 sto=pped 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 Departmi.=t of Industrial Accidents Office of Investigations 600 Washington Street Boston, luiA 02111 � Tel. #617-727-4900 Ext 406 or 1-8.77-MASSAFE Fax 4 617-727-7749 Revised 5-26-05 www.mass.gov/dia J. Date.. . . dP15,-0 ?" . .. . .. . . .. .. . . ORTH TOWN OF NORTH ANDOVER 0 PERMIT FOR GAS INSTALLATION SACHU This certifies that has permission for gas installation . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . at . . . . . . . . .i . . . .. North Anqo -er, Mass. Fee // . . . . . . Lic. No.. i. w"'a. . . . . . . . . ASINSPECT�R Check# 4117 MASSACHUSETTS UNIFORM APPUCATON FOR PERNUr TO DO GAS FIT nNG (Type or print) Date NORTH ANDOVER,MASSACHUSETTS _ Building Locations rPermit# / Amount$ Owner's Name 6 New❑ Renovation Q Replacement ❑ Plans Submitted �a 0 19 cU O F O PG o v $ q a SUB-BASEM ENT BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 3T H. FLOOR 6TH. FLOOR 7TH. FLOOR STH. FLOOR (Print ortype) one:• Cettificate Installing Company Name %zx�& Corp. Address ` D Partner. Bu.iiness Telephone ❑ Firm/CO. Name of Licensed Plumber or Gas Fitter �I INSLTRANCE CO``F.RAGE _ Check one' Ilia a curt liability InsUraace policy of it, substantial.equivalent. Yes ' NoQ Ifyou.have checked"J ,please indicate the:type caverage.try 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 ofthe Mass.General.Laws,a'nd.that my.si&ature on.tM!§.petmit application waives this requirement Check orie: Signature ofOwner.or()vvner's Agent Owi ❑. Agent I hereby certify that all ofthe details and Wormation I have submitted(or entered),in above application are true and accurate to the best of my knowledge and tliat all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions ofthe Massachusetts State Gas Code and Chapter 142 ofthe General Laws. Signature officensed Plumber Or Gas Fitter F,cTittyfrown le ❑ Plumber 1\ `� (LA Gas Fitter License NunlDer ❑ Master APPROVED(OFFICE USE ONLY) ❑ Journeyman Date. .007 7" TOWN OF NORTH ANDOVER �?�.�`,� �• OCL PERMIT FOR PLUMBING ,SSACHUS� This certifies thatX� . . . . . . . : . . . . ... . . . . . . . . . . . . has permission to perform . . -. . .. .. . . • • • plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . at . �. ... `• fi• • • orth Andover, Mass. 0 Feet', . . .Lic. No.. . . . . . . . ` :!-� . 1"=.W I SKCTOR Check #c;Po``? 5354 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Location 1k,11 Owners Name Lc�,— Permit# Amount Type of Occupancy ,�05 ►Vl New Renovation Replacement Plans Submitted Yes No ❑ FIXTURES z F O w w x Oa w w x z cc U O as w x a d a a as A 3 a A w O SM>M M11" M WM MHA OM 41H FL" 5M HOCR 6M HOM InH H = gm HOM ' (Pontn[o type) ` � ` Check one. Certificate Installing Company Name Corp. Andress El Partner. Business Telephone — Finn/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type 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 Owner 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 Massachsetts State Plumbing Code and Chapter 142 of the General Laws. 1►RA /Jnr By: �ignamre o1Cicenseaprmmoer Title Type of Plumbing License City/ icense mer Master Journeyman APPROVED(OFFICE USE ONLY No 2015 Date :Z9... .......... 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACMUS J This certifies that ...;4 ..r.�. -� .:�. `...Y.. !.:� ��. .�� ......... ram has permission to pe..—.—. ... -,—J ....... ......... ........ ... 0 wiring in the building of... ............................................... ...... ........ .North Andover,Mass. 1'7 Fee,j,.2.K........... Li c.N o.11/.;& Ur.. I4 Zir ..4...................., " �... ELECTRICAL WHITE: Applicant CANARY: Building Dept. PINK:Treasurer -�— o:ttcc u.. otitr The Commonwealth of_Massachusettsremic - - Dcparrmcnt of Public Safcry ' octv".Cy 1 rev Qfecket •- BOARD OF FIRE PREVENTION REGULATIONS_S,, CMR 1_00 3/90 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed M.eeo�dsnee with the M&".&chuicru Elmrscal Code. 527 CMR 12:00 (MEASE PRINT IN INK OR. TUF. All WO ON) Date City or Toon of �. .•.m �CeQ� Io the Inspector of Wires: the undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) qal Pqo-L . Owner or len-at Phone No M1 (�� Owner's Address ��V 1y Is this permit in conjunction with a building permit: Yes ❑ No 00�(Check Appropriate Box) Purpose of Building /)J am'_ ,J dL+�O Utility Authori=rion N0. ©UV6a o Existing Service Amps /� )VOVolts Volts Overhead ❑ Undgrd❑ No. of Meters New Service Asps / Volts Overhead ❑ Undgrd❑ No. of lieters Number of Feeders and Ampacity. Loc:tion and Nature of Proposed Electrical Work 160 4 en A Sle r ce - dtoLane No. of Lighting Outlets No. of Hot Iubs No. of Iransformers To tzl RVA 1 No. of Lighting Fixtures [Swimming Pool Above In� grad. 11F:-nd. ❑ Generato>'s RVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting l Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones Total No. of Detection and No. of es �g No.-of Air Cond. tons Initiating Devices No. of Disposals No. of Hut Ictal Total i sPo Pumps Tons YW No. of Sounding Devices No. of Dishwashers Space/Area Heating p,W No. of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices RW Local❑ Municipal [:]Other No. of Connection r No. of Water Heaters KW SiAnsf Ballasts I Lw Voltage No. Hydro Massage Iubs �No. of Motors Total HP OTHER: INSURANCE covEp ka: Pursuant to the requirements of Massachusetts General Laws I have a current LiabiliInsurance Policy including Completed Operations Coverage or its substantial equivalent. YES❑ NO 8 I have submitted valid proof of same to this office. YES❑ NO ❑ If you have the d YES, please indicate the type of coverage by checking the appropriate box- INSURANCE ( 'BOND ❑ ❑ (Please Specify) ' Estimated Value of Electrical Work S plracion ace Work to Statt Inspection Date Requested: Rough Final v Signed under the penalties of perjury: FIRM NAME I Co CM LIC. N0. /110(l,1314— Licensee agnatur � Tu..� / LIC. N0. _ Address LZ Bus. Iei. No. Alt. Iel. No. `7%(a OWNER'S INSURANCE WAIVER: I am aware that the Licensee does noc have the insurance coverage or ics suo stantial equivalent as required by Massachusetts General t.awr, ane that my signature on this perm i_c application waives- this requirement. Owner Agent (Please check one) 3929oz- Date......1.......................... f:IVA 1 02;• ``° "°off TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that / ;i� ............................... .............................................. has permission to perform ....-y '"- . ................................... wiring In the building of........j....... ............ ................................................. at.....`l-)T.... ......................... .North Andover,Mass. Fee..r6'.. ..... Lic.No............. ,/.. n'........................... ELECTRICAL INSPECTOR Check # / � � umclai use only Permit No. -3q, Occupancy&Fee Checked_ BOARD OF FIRE PREVENTION REGULATIONS.527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 5�j27 CyyMR 12:00 (Please Print in ink or type all information) Date To the Inspector of Wires: Town of North Andover The undersigned applies for as permit+to perform the electrical work described below. Location(Street&Number, 7 % 7J 1/ 11-74 4 Owner or Tenant:7Z A�li f- J� Y Owner's Address Is this permit in conjunction with a building permit Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building_ G z'�1 w Utility Authorization No. Existing Service Amps Voits Overhead ❑ Undgmd ❑ No. of Meters O � / New Service � Amps Volts Overhead 0/ Undgand ❑ No.of Meters Number oftFeeders and Ampacity. Location and Nature of Proposed Electrical Work p'G,sGA° Total No.of Lighting Outlets No.of Hot fuse No.of Transformers KVA Above ❑ In ❑ No.of Lighting Fixtures Swimming Pool grnd ❑ grnd ❑ Generators KVA No.of Emergency Lighting No.of Receptacles Outlets No.of Oil Burners Battery Units No.of Switch Outlets No of Gas Burners ` FIRE ALARMS No.of Zone Total No.of Detection and No.of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No.of Di sal No. Pumps Tons KW No.of Sounding Devices No./of Self Contained No.of Dishwast}ars Space/Area Heating KW Detection/Sounding Devices ❑ Municipal ❑ Other No.of Dryers Heating Devices KW Local Connection No.of No.of Low Voltage No.of Water Heaters KW Signs Bailases Wiring No.Hydro.Massage Tuds No.of Motors D /Total HP OTHER: 4 ! L, l S SGt/ Z/ 61�� /�I.S / j L-O I�� re�i r� ©tAm a5 INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES= NO = have submitted valid proof of same to the Office YES= NO = If you have checked YES please indicate the type of coverage by checking the appropriate box INSURANCE = BOND = OTHER =.(Please Specify) (Expiration Date) Estimated Value of Electrical Work$ Work to Start 7— /K a Z Inspection Date Resquested Rough l-,.ILL. 1,4 L-L Final Signed under the Penalties of perju // FIRM NAME �(ei.4r J oL LIC.NO. ?e Lkensee �' � Signature: 1 LIC.NO.6 f�- �" ,,!!YY c,, �1 Bus.Tel No.�� b Address )06 A+ Z7—)', cS� I����y�Q !�'7` Alt Tel.No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) G Telephone No. PERMITTEE $ (Signature of Owner or Agent) U