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HomeMy WebLinkAboutBuilding Permit #775-2016 - 45 SHANNON LANE 1/4/2016'��I�� yeti►, -N BUILDING PERMIT o� NORTH\ tt LED I6 TOWN OF NORTH ANDOVER �6 APPLICATION FOR PLAN EXAMINATION w 6/74 *DPermit No#: � Date Received ��ADAATED ,'PPS �5 gSSACHUs�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION �� S1 nr�yr 1-a.r�L- Print PROPERTY OWNER Print 100 Year Structure yesno MAP PARCEL'� ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resi ntial Non- Residential ❑ New Building rOne family ❑ Addition ❑ Two or more family 0 Industrial It ration No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: C�J r S trLl i h -A • d, WVy-t% t • ri -J QL,ok 't) d - Identification - Please Type or Print Clearly -U L . S� b OWNER: Name:_�r�� L Phone:?- V Address: 4'5 - Contractor S Contractor Name: W Email: gwJih.i tr i hSvl(,rt Address. Po 1"3k3x 344 WdN cl"e 3 S -U - N'Q3 Supervisor's Construction License: 01S'U 2- Exp. Date: � I [ I Home Improvement License: [ � 34 0-3 ARCHITECT/ENGINEER Address: Ex Date: LO t Exp. t i `? Phone: 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: $ q3m . S FEE: $ 3 Check No.: Receipt No.: 2 , NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ 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 PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed On Signature, Reviewed on Siqnature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: "Planning Board Decision: Conservation Decision: Comments Comments Zoning Decision/receipt submitted yes Wafter & Sewer Connection/signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osaood Street F,.IRE DEPARATMENii Temp>pumpster.on.tsite ,yes__ . Locatedjaf 12„4�MairSrStieet _ . Fire�Departmentsignature/dafe COMMENTS. Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: 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 NU 1 tb and UA I A — (l -or department use ❑ Notified for pickup Call Emai Date Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 Location 4,q 5 ' ` o ^'N r -- No. Check 4tl4�1 r , ry ..,"1 u Date f `� k TOWN OF NORTH ANDOVER Certificate of Occupancy $ _ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector v 0 C � N 0 '0 O CD D O CL =• N � O � 0 vCD CD 0Q C 2 CD CD O CD �� C O CD CO. C I � v '0 Z CD 0 0- O 70 CD a CD i u ii O h CD N O O� (O O W Q. co X CD to N 0 N y 00� c _ cCL CDC CD n 0 rtO. 0 m o _� - c N -q N f/l CD TI O O r* CL Ill W F CD N 0 cD 2 CL D) C CL 0 N ,.r • O W C CD CD � CD O O 0 < CO o o 0, a rt DoN �. Q. o c0 O O_ - v, < CD �� o CD�< CL O `D W� CD d Vi At0 -'o vi o 0 0 W Uzw c �• D0 CD 0 0 CL 0 Ln O ry (D r Ln N Co � m 7T -o m^ v 3 T N WT S G1 °�° N N V7 < ;a S mM m n V T d x 0Cq S C G) M T d n f 7 x OIQ S m 7 i1 O = W C 0 z m O W W 0 (DN 3 4 T Q \ S ' W A o D = y 0 Lotil �z� Federal ID # RISE Engineering lit Contractor Registration No MA Contractor Registration No A divisloa ofThlelsch Engineering GT Contractor Registration No 60 Shawmut Unit N2, Canton, MA 02021 CONTRACT wMm 339.502.6335 FAX 339-502.63A5 1 1 R i SPage 1 PRClG12AM ams CONTRA" M Tana rr'rro scam MR CMA -RES EuowEWROAND1WCUSTOM fORWORKas ENGINEERING mcltmEe ow _....._........... ... CUSTOMER 141014E DATE cum # WORK WWcR Richard Lowe (214)562-5946 03/06P-015 411618 000002,, ...... 19RVM SWAIM eauAc STREET 45 Shannon Lane 45 Shannon Lane �tFR1RCE CIrY,aTaTE,Xtp ..�._..._........ ........._..............._...._..,.__._..._..._._....._.�...._6Rt.MD GrTY,STA'IE.DP._...,...___,,.,_,.>m�.._.4 k.e�'. North Andover, MA 01845 North Andover. MA 01845 Rt£ JOB DESCRIPTION $0.00 HEALTH & SAFETY: Wctuherization wort: cannot proceed until the insufficient draft issue is fined. $0.00 AIR SEALING}: Provide labor and materials to seal areas of your home against wasterul, excess air leakage. This worts will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be felt with a heaBhfal level of air exchange and indoor air quality. Materials to be used to seal your home can include caulks, foams and other products. Primary areas for scaling include air leakage to attics, basements, attached garages and other unheated areas (windows are not generally addressed.) (8) wvrking hours. At the completion of the weatherization work, and at no additional cost to tate homeowner, a final blower door and/or combustion safety analysis will be conducted by the subcontractor to ensure the safety of the indoor air quality. $680.00 AIR SEALING ADDER: (4) wonting hours. 5340.00 DAMMING: Provide tabor and materials to install a 12" layer of R-38 unlaced fiberglass Batts to (120) square feet for damming purposes. $246.00 ATTIC FLAT: Provide labor and materials to install an 8 layer of R-28 Class I Cellulose added to (1860) square feet of open attic space. $2,548.20 KNEEWALLS: Provide labor and materials to install 2" FSK faced semirigid fiberglass board insulation to (1"2) square feet of kneewull area. $252.00 ATTIC ACCESS: Provide labor and materials to insulate the back of (1) attic batten with 2" rigid Thcrmax board. Weatherstrip the perimeter. S660.00 ATTIC ACCESS: Provide labor and materials to install (t) easily moved, insulating Cover for the attic access folding stair. A small flat surface of plywood will be created around the opening within the attic, This will allow the cover's integral ucatttcr-stripping to restrict sir leakage. $237.65 VENTILATION: Provide labor and materials to install ventilation chutes in (18) rafter bays to maintain air flow. 536.00 IF RISE Engineering TT r _ A division ofThietsch Enginccring f E. 60 Sh winut Unit 02, Canton, NIA 02021 339-503-6335 FAX 339-502-6345 DISE ENGINEERING Federal ID # RI Contractor Registration No MA Contractor Registration No C3 Contractor Registration No CONTRACT Page 2 PROGRAM THffi CeNTRACt s ENTERED 04TOBETWHEN KNEE CMA -HES WMICERMOAND THE CUSTOMERPOR WORKAE DESCMD 89LOW .................... ._ _.........,, CUSTOMER PHONE DATE CUENTY WORKOROER Richard Lowe (214)562-5946 03106/201^5 m 411618__._. _ 00002 ..._...... EERVK;E STREET RPLUNO ETR$ET 45 Shannon Lane 45 Shannon Lane SERVICE CTtK STATE, ��. WLiJtiO CITY, ETATE,21P ... North Andover, M `; North Andover, MAO 1845 DESCRIPTION Total: $4,399.85 Program Incentive: $3,020.00 Customer Total: $1,379.85 WE AGREE HEREBY TO FUIUM SERVICES -COMPLETE n{ ACCORDANCE VM ABOVE SPECIFICATION& FOR THE SUM OF ***One Thousand Three Hundred Seventy -Nide & 851100 !Sollars $9,379.85 DO �f tq � NpT EXECt1TEA1NTFDk 30 DAYS. ES To REMIT AMOUNT DUE W FULL. MEREST OF 1% WIL BECHARGED MONTHLY ON ANY k #WRAN:EES. RKSNiB OF REC}EtO#, ECNEDIiFIkD, AHDC#HTW=*RREOIETRATIDN, CONTRACT IF THERE ARE ANY 6LANK SPACES _... �� _ ��,...._,...__.. R� .. _�_. _..... . _.._.. CWTOM11ft ACCE1*r DATEGF ACCEPTAkCE ........................_......._....__._.........,.._.,.»._._.............._.......,....._....... _..____._ ACCEPTANCE OF CWMtACT.THE AWYE PRIM, SPEWMATMUS ANDCONDff#M ME SAMPACTORY TO US AND ARE HEREBY ACCW10. YOU ARE AWHORM TO 06 THE WORK AS SPEClP7ED. PAYNEHt WR,I. nE EtADE AS OU1'LWED ABOVE i S 3 OWNER AUTHORIZATION FORM i -G owner of the property located at hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perfomt work on my property. The Commonweafth of Maswhaettv Depwtment ofIndustrial Acddenh Orke of Investigations I Congress Street, Suite 100 RoVon,MA 02114-2017 w*,wxws.gov1dia Workerr' Compensation Insurance Affidavit: Buflders/Contractors/Eitictriicions,/Plumbers Aypileant Information Ream Print Inibl-v Name (*minewormizaiioniindividual): IAA�:f.r- Phom M AILIM; Are you an employtr? Chats the appropriate box! Type of project (required): 1, , am a employer with 15 4 1 am a general con. tractor and I 6, New construction employees (full "d/or part-time).* 2. Q 1 am awic proocior of partner- have hired the contractors listed on the attached sheet 7. Remodcling ,ship and bavc no cmployces These sub-*omractars have S. Dmolition working for me in any capacity. cmployce,-and have workers' 9- [3Building addition [N* workcrs'comp. imaean" requiTed.] comp. imiuranccJ 5, We ate a corporation and its 10,C) Electrical repairs or additions I am a hameowmer doing all work offiects have exercised their I L0 Plumbing repairs or additions m C [N,,o workers' comp. tight of=mption per N4GL 111] Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13.0 Other employee& [No workers' comp. insures required.) *Anyapplicant tires check& box 41 nialaWfill out the wcaun irSbmauon we doing all wmk and ftr him otft6dccmr40m- mugv&-mit arm affidavitindica fingswh, 'Conftcwn that Otckthls tox mug IwKhod an "huoul ehftf st"ing We asm or the sub -contractees and state iklwArr or nwft-rc cnntiv% haw C"Joyeft. If ft $UbVM%-ACM--M haw cn7� ffia n#4t proi& Lh6l woAtTs, cotta. policy r= r. ............ I am art emplayt? that isproridMg 11arkerv'compensation imurancefor inp employees. Below is the patioandjob site Insurance Company Narne:-Ata "t-AY-Aw Policy # or Self in& Lic. Expiration Date: -Lo 3 S�I 14 Job Site Address 4i Y.-ShLAMn Lo -m-4- cityistatezip:w , VN ri 0�(Oqs, Attach a copy of workers' compensation policy declaration page (showing the policy number and expiration date), Failure to sem coverage as mpircd under Section 25A of MGL c. 152 can lead to the imposition aftnimmial penalties of a s civil ORDER d fine UptOS1,500.00aa&oronc-yearimprisomTmi, as well a: wil penalties in the foray a STOP WORK an a fine of up toS250M,a day against the vk)tator. Readvised that a copy of this statement may he forwarded mAcOfficc of Investigations of the l) for is vurante coverage verification, I do hereby eerdfy under the pains andpenaftiet of perjury that the ififormation provided above is true androrrect, official av o4y. Do not write in this area, to be completed by city or town offlcial. City or Town: Permit/ sense U.... 1 Authority (circle one): 1. bxordof Health 2. Building Depammul I CitytTowo Clerk 4. F.1ectrical Inspector S. Plumbing bispector 6. Other Contact Person: Phone #: ACORD" CERTIFICATE OF LIABIUTY INSURANCE � 15M T;#IS CERTIFICATE IS IS%eD ASA AATrM OF 1009MATIE#N AND COWERSK RIG K S UMN T"E CVlTJ tCATf SOLDEi€. THIS CERTIFICATE DMS W AFF itlosA:TfVI!a 0A NMATIVEL'Y AkftbeERME> Of.. ALTER Ta tE CD U'Aa E AOVRptp BY THE PoL=s snow. Tats CEfRnFICATE OF INStPRMCE 00tS NOT COMMTU!`E A CONTRfiU BETWEEN TRE IS$VIfRS thSUORI53. &ffWWlZF0 APRE5WAnW OR PRMr-EA, A.10 THE T CERYIPICAE tit tLD R. . . . _. __................... . IMPO tTAW. It the coWk,4e;Z;;t 70 M OVAL lvsuavE powy,;;s} Mast w ;;ac4#+s , 17 SS oGAMN IS wAram wbied to tt tams VW tW tt Oft Of #+t WiCya VWWn Pato MY MAU "ftfSeMWA, A 5ttt;?rsaem On ft$ temkOtt do r awltr €i# is tO the czndlmte h4ldw 4n "tu of Clayton i atmos 2 km AWngy tete * s Se*W Ats twd R4sk SeMces 160 mod ampwn St PC1 Box so farm itix r�,a t856� xis BEIEI Ho"ke MA 01"I s4,�acta°�*cs 9Y _. thiw It"Ilmon &41F45iNF it PO Oft 4 1p r4tlt MA iilou THA t9 TO CERTbFY THATrK POLCU OF WSURAWX 0STE$} BROW *,AVE BLEXiSSUM70 rHf 04URED W95 ZM FFR THE POJCV PNW— INDICATED, NOTWYMANW4 ANY R i13ti2£.A"''T, TEW OR Cc ;,cif ON OF ANY tONTRKTOR 07 FER IXXMFt47 y nK R£ ECT M VMCH TeG ££RTMCATE't MAY eE tt UE J OR MAY PC -MAIN, TKI OIWW= A BY TILE KAJOES UESCRISED t RE6i IS Sii T Tia ALL ThE TERMS, EXCLtJSfC*JS AND COW*U" OF StX PK.ti:eM, L OrM SHC*^ MAY RAVE ECEN REEZUCM BY PAZ . aFa�w. u.�r.ery Eke (Kfis:X?I£+}�E to u Baa r*t:'wRY"'" S.. c O 'n"wo D € 3 wr T'v Am. v,,,,,��,� � s stgmt'm A Y .. s iTx.kfaf,Kik�sp - ;s A.itik 'WQi39FittY. Aii7S��' Au"> ,YLap1„ iftdS D Cl ALMA _ LUMMAi9ia Z) o=. Eks^H i3iSlYEi�F;. � BxCm" sokoym Lt1F�W" dQ��4dJE'FFa�k r:%$:ut i7iklKR,w-ANERttXIM E'" .�s x'i MA0.RPM27 'a , C"ibTS 11'3tI$ T6 €L£MwwCi#�t�' j }Eq3 � Y�"itl1P6'�P �i C95Eds'�*'�4AG'�'tif/�' D£'8�"4;ti+C7�`iT�kF€x�17TMs 4u1tliT F S •.. AfJ4 :�'! ".,., >8"$Y . 04 5NJlR 4n'M6L 3 qS#F Q1�tll�Pf>Ca11bpD!� $4MPA4®+'+� 1ti1M A4 #i:S �!.fART"R/C{fi�: i+Cli €/E'fleA� i C iEkr7GSDiR Sd��YirC,£.3.1\ 17Vf'4 SisC>=AW OF 7-W FS%T OESCIPABW t'U`- WS BEa ANCMl= BEFOK_ i ( THE C 'AAr*N DATE IKRE , W)TRI WEL BE t'kE'L. GOt tlr $YWl ACZ0RUAMZ 31 nK TK POLCY PRW4XPt"', 50wftmnston ftatt AODRD 25 (2010,/05) 8AAC 3139 A� ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 7/7/2015 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 INSURED, the policy(ies) 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 Nancy Usher NAME: y Martin J Clayton Insurance Agency, Inc. PHONE Ext).. (413)536-0804 FAX Nps; (413)534-7874 (Af1649 Northampton Street E-MAIL ADDRESS: P. 0. BOX 989 INSURER(S) AFFORDING COVERAGE �— NAIC # — Holyoke MA 01041-0989 INSURERA_Nationwide Mutual -Harleysville _ NATIO INSURED INSURERB:Allied World Natl Assurance Co Gauthier Insulation INSURERC: 44 ESSEX ROAD INSURER D: IPSWICH MA 01938 INSURER F: COVERAGES CERTIFICATE NUMBER:CL157701379 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 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 WHICH 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. INSRADDL SUBR - _ i POLICY EFF POLICY EXP LTR I TYPE OF INSURANCE POLICY NUMBER D LIMITS ACCORDANCE WITH THE POLICY PROVISIONS. X COMMERCIAL GENERAL LIABILITY AUTHORIZED REPRESENTATIVE WESTBOROUGH, MA 01581 Daniel Sullivan/MEG EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE 1XI OCCUR I $ 50,000 DAMAGE TO RENTED PREMISESSEa occurren e) MED EXP (Any one person) _ $ 5,000 X GL43487F 7/6/2015 7/6/2016 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,0 00 POLICY JECOT- [—]LOC $ 2 , 000 , 000 PRODUCTS_ - COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ . BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ DAMAGE (Per accident) NON-OWNEDPROPERTY HIRED AUTOS AUTOS $ _ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE -- ----_ $ B EXCESS LIAB CLAIMS -MADE DED RETENTION __1,000,000 $ BE020792125-194985 10/18/2014 10/18/2015 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ NIA (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below I I I 1 $ ASE -POLICY LIMIT DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) CSG, NSTAR AND NATIONAL GRID ARE LISTED AS ADDITIONAL INSURED r`FRTIFIC'.ATF NAI nFR CANCFI I ATInNI ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD P5Ptrd'5tbd with pdfFactory trial version www.pdffactory.com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MASS SAVE PROGRAM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CONSERVATION SERVICES GROUP, INC. ACCORDANCE WITH THE POLICY PROVISIONS. 50 WASHINGTON STREET AUTHORIZED REPRESENTATIVE WESTBOROUGH, MA 01581 Daniel Sullivan/MEG ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD P5Ptrd'5tbd with pdfFactory trial version www.pdffactory.com cC: m x :0 J�54*, :c > > mo 'S. S F. Fn t,o A m 0 va tai, tz > z M 0 to irk qui, AilB- 'IlFill o �pi w OD 0 va tai, tz > t to irk qui, AilB- 'IlFill o �pi w OD 0 tz C> f K 131 n. (A LA C> cu U e A P Commonwealth of Massachusetts Official Use Only 4 a Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice o his or her intention to perform the electrical work described below. Location (Street & Number) �� _a Owner or Tenant Telephone No. Owner's Address e Is this permit in conjunction with a buiWin permit? Yes ©�No F1 (Check Appropriate Box) Purpose of BuildingSj�h, Utility Authorization No. - Existing Service AD B Amps % z / 07 Volts Overhead ❑ Undgrd No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table maybe 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- ❑N rnd. grnd. o. o mergency 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 No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number Tons ......... KW ���.................... No. of Self -Contained 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 Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of ff7res. Estimated Value of Electrical Work: dSQfJ, (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under thepains and penalties ofperjury, that the inform: ion on this application is tr a and complete. FIRM NAME:. �. ri ..(� ,�' LIC. NO.: �O Licensee:. ,t e �C�� Signature LIC. NO.: (If applicable, en�'exem t" inthe-license num r line.) Bus. Tel. No.: Address: e YC d2SAOT Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requir s Department of Public afety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the g permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be fil€d' 1 on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall be limited as to the time of ongoing construction activity, and may be.deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 1fl Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INVECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: 444 17 Inspectors Signature: Date: /1--/ j FINAL INSPECTION: Pass EN Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: j Z DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com J r4 The Commonwealth of Massachusetts { Department of Industrial Accidents I Congress Street, Suite 100 .F Boston, MA 02114-2017 ` www mass.gov/dia o�M sV' V9 -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual):- Address: City/State/Zip: 1 •- Are you a employer? Check the appropriate box: 1,;a employer with_employees (fiill and/or pari time).* 2.L] I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.E] I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.[]I am a homeowner and will be, hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.FJ I am a general contractor and I. have hired the sub -contractors listed on the attached sheet. These sub -contractors have einployees and have workers' comp. insurance.t 6.FJ We are a corporation and its, officers have exercised their right of exemption per MGL c. 152 §1(4) and We have no employees. [No workers' comp. insurance required.] Type of project (required); 7. ❑ New'construction 8. emodeliidg 9. ❑ Demolition 10 [] Building addition 11.[] Electrical repairs or additions 12. [] Plumbing repairs or additions 11 [] Ro6f repair6 14.n Other *Any applicant that checks box #1. must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating They arc doing all work and then hire outside contractors must submit a new affidavit indicating such #Contractors that check this box must attacfled an additional sheet showing the name of the sub -contractors and state whether or not those •entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. X am an employer that is providingworkeps' compensation insurance for• my employees. Below is the policy and job site information. 72 ` a ' J I <C I( I/ACC s Insurance Company Name: �-• 0 Expiration Date: G Policy # or Self -ins. Lic. ii Job Site Address:— S La City/State/Zip: dl pw d� N . . Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date . Failure to secure coverage as required under MGL a. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certify under tlaepains andpenalties ofperjury 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 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone r ', 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 enferprise, and including the legal representatives of a deceased employer, or the receiv6for trustee 6f 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 requiired." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub=contractors) name(s), address(es) and phone number(s) along with their cerEificate(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 cavy 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/licenso number which will be used as a reference number. In addition, an applicant thai 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. Anew affidavit must be filled out each year. Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MA.SSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia