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HomeMy WebLinkAboutBuilding Permit #276-14 - 17 MARBLEHEAD STREET 9/25/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page _, Pring PROPERTY OWNER__ Print T100 Year Old Structure. yes o n MAP NQ: PARCEL: ZONING DISTRICT. _ 'Historic District yes no r -Machine Shop Village _ yes . _ no =_ TYPE OF IMPROVEMENT PROPO D USE Resio4htial Non- Residential ❑ Ne uilding One family ❑ dition ❑Two or more family [I Industrial Alteration No. of units: [I Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic El ❑ Floodplain Wetlands, Watershed District - EJ Water/Sewer - DESCRIPTION OF WORK TO BE PERFORMED: 7� Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: _ a _ - '1_ G�- Phone- Adds neo� ' Address: Supervisor's Construction-License: � 57Y,/- 34 `- — . Exp: Date: _ --- Home Improvement License: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT-$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ I 0 Check No.: ��i� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Si naturelof.A 'ent/Owner, _ F Slgature of contracfo a Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Building Department The following is�a list of the required forms to be filled out for the appropriate permit to.be obtained. Roofhg, Siding, Interior Rehabilitation Permits ` Building Pp Permit Application Li Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ' o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Li Building Permit Application Li Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Li Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses a Workers Comp Affidavit Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract u Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit h In all cascs if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm:tted with the building application Doc: Doc.Building Permit Revised 2012 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE_OF`:SE DISPOSAL Public Public Sewer ❑ Tanning/MassageBodyArt ❑ Swimming Pools ❑ Well ❑ Tobacco.Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc.. ❑ . Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE:APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS i .CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature v COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments j - Water& Sewer Connection/si gnature� Date Driveway Permit i + DPW To-,,v;! Engineer: Signature: -- Located 384 Osgood Street FIRE-DEPARTiVIL=''Nt -Temp Dumpster on site yes no L•ocated-at 124,Mairy Street—-> Fire"Depa`rtmerit"sigiiature/date "x, ,, ,+ TS_ COMM.ENt, f i Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ .Total land area, sq. ft.: I ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A-F and G min.$100-$1000 fine NOTES and DATA— (For department use F I II i i ® Notified for pickup - Date Doe.Building Permit Revised 2010 L Location No. ?' t Date • o - TOWN OF NORTH ANDOVER, o e .y Certificate of Occupancy $ Building/Frame Permit Fee $ Inf: Foundation Permit Fee $ Other Permit Fee f $ TOTAL $ Check# L3t� Building Inspector NORTH Town of t E ndover No. n ver, Mass, 1,01!1 O c LANE 1 COC MIC Nf WIC" A0RgTED r'P�`,`'�5 S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System 11AA .1�{� THIS CERTIFIES THAT ........R.1%.CAM .......tit ............................................... BUILDING INSPECTOR t�eA ........ ... has permission to erect .......................... buildings on ....1., Foundation......... ............. .......................... +' ` Rough to be occupied as ......... ...... ........ ....... .. ....................................................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service ........... .... . `. .Y.................................... Final BUILDING INSPECTOR GAS.INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. T. "OUR PROOF IS ON s�lmbe _ EIN # 51-050-3313 YOUR ROOF" Haverhill, MA 978.374.9224 BBB_ MA Reg. HIC # 149221 oofin Laurence MA 978.687.7339 � • MA Lie. UCS # 78130 � •. S[.vi.ce.Y 932 co, � Hampton NH603.929.9224 Single-Ply License# 1711Hampstead NH 603.329.8200 Toll Free 1.888.SOS.ROOF 265 Winter Street Haverhill MA 01830 _ *Licensed *Insured *Factory Trained *Factory Certified Name: Richard McCubbin Date: 09/06/2013 Telephone: 978-686-4250 E-Mail: N/A i Billing Address: 17 Marblehead street North Andover, MA 01845 Job Address: Same SCOPE OF WORK 3, 000 SF Prepare - p for re roofing by ensuring all safety measures in accordance with OSHA standard regulations and landscape is properly protected. Remove existing layers of shingles down to roof deck and dispose of in a legal fashion from the job site. Inspect wood deck, if'we discover any rotted wood, replacement will be performed at* $3.95 per ft for boards and $65. 00 per sheet of plywood if we need to skin over entire area over the cost below. If wood is sound we will re-nail and loose wood and prepare for roofing. Install 8" drip edge to all rakes and eaves. Color TBD. Apply Ice & water shield (UNDERLAYMENT) as per manufacturers' specifications 6' and up all roofs to walls. Apply premium (UNDERLAYMENT) to the balance of the exposed wood deck. Re-flash all plumbing stack pipes, and any roof penetrations as required and dictated by good roof practice to ensure water tightness. Install a new: 50 Year Architectural shingle. Color to be selected by owners. All nailing is Hurricane. Furnish and install a new attic vents. All debris generated by Lambert Roofing Co. , Inc. will be cleaned up and disposed of from the job site in a legal fashion. Under no circumstances will the watertight' integrity of the j building be compromised. *Denotes potential additional costs above the total job cost. UPON COMPLETION AND PAYMENT IN FULL, ROOF SHALL HAVE A WORKMANSHIP GUARANTEE FOR A PERIOD OF 10 YEARS HONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY AND A FIFTY YEARS HONORED AND ISSUED BY THE SHINGLE MANUFACTURER (SEE WARRANTY TERMS AND CONDITIONS AT WWW. -TKO. COM). i TOTAL COST•••Nine Thousand . . . . . $9, 000. 00 NOTE= we will also apply a credit for whatever IKO is providing for materials TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE Payment will be made according to the following work schedule: 1/3zdown upon delivery of materials, upon completion payment in full. (Law forbids demanding full payment until contract is completed to both party' s satisfaction) You may cancel this agreement if it has been signed at a place other than the contractor' s normal place of business, provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram or by delivery, not later than midnight of the third business day following the signing of this agreement. See attached notice of cancellation for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ANY BLANK SPACES Acceptance oof? the Contract Proposal Owner(s) Signature(s) : ,.'te r '4.4.1p o > a�c' ��'Z►,� Date: `I � /1�_/ �' 3 Contractor' s Signature: Date: O �F/ 061 3 www. lambertroofing. com Company Insurances TGLRC Inc. DBA Lambert Roofing Company will provide certification of insurances, demonstrating that we are fully insured for worker' s compensations, general liability, automobile liability and an umbrella policy. This documentation will be sent through the US mail to the above named party if not already provided. TGLRC Inc. dba Lambert Roofing Company agrees to: • Commence the described work on or about Fall 2013 • Complete the described work in approximately 2-3 days. • Not be held liable for delays due to circumstances beyond our control. • Not be held liable for any damages to landscape and or fixtures due to circumstances beyond our control. • Not be held liable and not covered under the workmanship warranty, for pre- existing conditions including but not limited to: • Mold and or wood rot, defective, faulty, rotted or worn building counterparts such as, but no limited to: siding, roofing, masonry, plumbing and windows, all of which may jeopardize the watertight integrity of the structure. • Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence. • This contract is the complete contract unless a signed Change Order has been executed between TGLRC Inc. DBA Lambert Roofing Company and the Homeowner/Business Owner or Agent. Coniractor Registration All home improvement contractors and subcontractors must be registered, any inquiries about a contractor or subcontractor relating to a registration should be directed to: Contractor Registration: a Director of Home Improvement Contractor Registration Board of Building Regulations and Standards One Ashburton Place, Rm. 1301 Boston, MA 02108 (617) 727-3200 Home 1mpro vemen t Contractor Law: Consumer Information Hotline Commonwealth of Massachusetts Office of Consumer Affairs and Business Regulations 10 Park Plaza, Rm. 5170 Boston, MA 02116 (617) 973-8787 For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General (617) 727-8400 AND/OR Better Business Bureau (508) 652-4800 (508) 755-2548 (413) 734-3114 Cancellation You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller, which may be in the main office or branch thereof, provided you notify the seller in writing at the main office by ordinary mail posted, by telegram sent or by delivery, no later than that midnight of the third business day following the signing of the agreement. G INITIALS s, . C, J Ste^ b CS-078134 RICHARD J LAMBERT 245 WINTER STREET Haverhill MA oigm 06102/2014 Office of Consumer Affairs ande usinrs�=gulation ws 10 Park Plaza d Suite 5170 Boston, Massachusetts 02116 Horne Improvement Contractor Registration Registration: 149221 Type: Private Corporation Expiration: �1'216i201& Tr# 218746 T.G.L.R.0 dba Lambert Roofing Company RICHARD LAMBERT - ------ ---- — -- 265 WINTER STREET ------_--- ___..--- -- .—.. HAVERHILL, MA 01830 — -- — — -- - Update Address and return card.Mark reason for change. Address '' Renewal 1 Employment i_1 Lost Card I ACORU CERTIFICATE OF LIABILITY INSURANCE DATE)MMr0D `...—� o8/zs/z013 o13 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. iMPORTANT: If the certificate holder is an ADDITIONAL INSURE?, the policyties) must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Jerrold FCameras _NAME: ALLAN INSURANCE AGENCY INC. PHONE (978) 745-5905 FAXC. (eTs) Tas-saea 63 1/2 Jefferson Avenue 2nd Floor E-MAIL .Jerrold[allaniasurance.ccm P.O. SOX 511 INSURER(S)AFFORDING COVERAGE MAIC a SALEM ITA 0197 0-4 511 INSURERA:First Mercury Insurance Co i INSURED INSURERB:Safety Insurance Com an _ TGLRC Inc. INSURERC:Chartis Insurance Company dba Lambert Roofing Company INSURERD:Ace American Insurance Co. 265 Winter Street INSURERE:Ace American Insurance Co. Haverhill MA 01830- INSURER F: I COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEU BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WFIiCH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. AD L;;UPOLICY NUMBER MOLIC YrFF MMOt/LDDMVYY -� LIMITS LTR i TYPE OF INSURANCE GENERAL LIABILITY / / / / I EAGHCW.C.LJRRENCF w 1,000,000 fX }r f)MMf-Rc rAr GI.N[:RAI. IIF HILIT"Y ; )1'i'-MArr.I(TR ) T) �l- I I ! / i �PREttI_ [S_jE�Y irrP,x 5 50,0001 A i i c SAtW;- MA01. )AF FStF , . e $ - 1 000 PERSONAL.A A0V INJURY $ 1,000,000 -GENERAL AGGREGAIE $ 2,000,000 GFNT A(3GRECA1r LIME)APF'i-11 S PFR f / ! / PiRomi_CTS-COMP/OP AGG 2,000,000 —,PC1LIi:Y X PRO to C AUTOMOBILE LIABILITYr OMBINED SiNr)E(WI I1000 f 000 25 JY 1'� ( at Y .i'c? X-'1 r'IiCOl! t:0 I 62fl3813 07j16/2023I'07/16/2019, (iOD1 Yt.dJUr�r,N�rac.".�a.tl % ~��--�� aJlrJa Nt}N-C)M?JI-D PROPERTY DAM.AGr X IIIRED A.UT(.15 I X At 11OS UMBRELLA LIAR X OcctjU f f ! ! EACH OCCURRENCE 8 5,000,000 C X ! Excessune CLAIM",M;DI.' � ! ! !AGGREGATE — 51000,000 UFU LRF TENTION$. I 0037721404 11/21/201211/12/2013$ WORKERS COMPENSA I lot I � I - ( / L d Ii AND EMPLOYERS LIABILITY Y I N I.r,)IAYllItL`.�r1 X---- ANI, ANv ROPR)EFORIz RTNERI x—.'UriV1; EL EACH ACCIDENT $ 1 00Q 0QQ D )i"8�iC v/ML MHER E'. Jl1)0FD? N I A ----.-----.� 1_.__-_._.L...._._ (Mandatory in NH) 58562781 OBI2B/2012 8/28/2013:E L C115EA5E-LA EMPLOYE $ 1 000 000 [yes. IP r[ undef Gt / sJ r�p/ --- UfSf.:HIPTIONOFOPERATIONS belcm ++ ,(J (Q f/ /O r 08!26!2033 8/29/2014. iEi DISEASE POLICY LIMIT $ j 000 000 i Workers Comp & Employers i 6S62UBSB75090312 12/22/2012112/22/20131 1,1,000,000 E I Liability for NH ! I I ! ! ; y 1,000,000 i DESCRIPTION OF OPERATIONS t LOCATIONS I VEHICLES(Attach ACORD 501,Additional Remarks Schedule,A morn spacii is requirud) I CERTIFICATE HOLDER CANCELLATION Lambert Roofing Co. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 265 Winter Street AUTHORIZED REPRESENTATIVE Haverhill MA 01830- j . rf ACORD 25(2010105) / y/, ©i988-2010 ACORD CI�RPORATION. All rights reserved. INS025 ^cs;---' The ACORD name and logo are registee, d marks of ACORD The Commonwealth oflMlassachusetts - Department oflndustriglAccidents Office of Investigations IF 600 Washington Street Boston,MA.02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Ele,ctricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zipr,��/ Are you an employer?Check the appropriate box: TYPa of project(required): 1I am a employer with 4. El am a general contractor and I 6. E]Now construction 1 employees(full and/or part-time).* have hired the sub-contractors 2.❑ I 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. g• ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.El Electrical repairs or additions required.] officers have exercised their 3.El 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 a ired.re q uemployees.[No workers' 13.❑Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workerscomp.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 S elf-ins.Lie.#: r- Expiration Date: _ lO S Ci /State/Zi Job Site Address: tY R Attach a co of the workers'compensation-policy declaration page(showing the policy number and expiration date). PY P 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 of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certio under the pains andpenaldes ofperjury that the information provided above is true and correct. - Srgnature Phone 4: Official use only. Do not write in this area,to be completed by city or town offrclal. 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 - - f'nntarf Pprcnn' 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,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any ofits 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-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 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 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(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. Anew 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 orpermit 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 should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Gomzx mwealtl of Massachusetts Department ofladustrial.Accidents Office ofTnyestigatiom 600 Washington Street EQston�MA.02111 `QJ,##617-72..7-4900 est 406 or 1:-877,M.•ASSAFE Revised 5-26-05 Fax 4 617-727-7749 +� Date....... ........................... f HORT►,, 3?�•`����-+.3e�ppt TOWN OF NORTH ANDOVER PERMIT FOR WIRING ACHUS This certifies that .......................................... has permission to perform ......... . �L�L`...............^.. .........- 1 'y wiring in the building of................. ............................... at.... .T&A.0-ViE 1-r- . .......... ........ .. ... .North Andover,Mass. Feel.9""'.'.. Lic.No. D 1.3i', ....... ........ ..1 .t... . .... Et,ecrwcAL IIvsreci o Check # UZ y r; 0.590 Official Use Only Commth o� a��actxu�e>' Y _. _. onweal— — Apartid /.c7ire - - Permit No. .--. —-- -- -- – neol �ervice�---— . 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 Y11 ),52 CMR 12.00 (PLEASE PRINT IN INK OR TYPE AL INFORMATION) Date: (J ! � Z City or Town of: �t91^7 Ae/c"r To the Inspector of Wires: By this application the undersigned gives notic of his or her intention to per the electrical work described below. Location(Street&Number) 4�G, �q 7 Owner or Tenanty5ct h Telephone No. Owner's Address d- /\ 4 611 Jai Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service f 4e' Amps ZU / ZtO 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: pQ` o-,A9-1 r \� dog Pct 7 , ct74c,� r-d►7. /7 ✓ Com letion of the ollowin 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. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.ofDatinti Devi es No.of Ranges No.of Air Cond. Total No.of Alerting Devices ns No.of Waste Disposers Heat Pump I.NYM49y Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KWLocal❑ Municipal ❑ Other Connection J No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or E uivalent No.of WaterNo.KW No.of No.of Data Wiring: `w Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: 00 Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value o El tr' I Work: (When required by municipal policy.) Work to Start: D L- Xl Inspections to be requested'm 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 cover a is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the p ins and pent�Ities o per* ry,that the information on this application is true and complete. FIRM NAME: `ki��'1 l' /C- �c d� LIC.NO.: r Licensee: o,, r �1(�/c l SignatuLIC.NO.: (If applicable,er r "e eempt"in thg license numb r line. Address: �` 41611 I-A VV y?q 1k6(Lc,4411 Bus.Tel.No.I U,1W Q �� Alt.Tel.No.: *Per M.G.L.c. 147,s.5f-61,security work requires Department of Public Safety"S"License: Lie.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 Signature Telephone No. PERMIT FEE: $ i ' ��-,i V i�/� D � r I�� The Commonwealth of Massachusetts Department of Industrial Accidents — --- --Offtce-of-Investigations — 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/Organization/Individual): Address: 1 City/State/Zip: dell , 1<< /4�ole � Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction y,erfployees(full and/or part-time).* have hired the sub-contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. E]B 'lding addition j [No workers' comp. insurance 5• El are a corporation and its required.] officers have exercised their 10. Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 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.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f 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: N 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 certify un r the pain d p allies�jojfperjury that the information provided a�b-eve is true and correct. Signature: U— --- 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: