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HomeMy WebLinkAboutBuilding Permit #12831-1 - Fountain Drive 10/29/2015 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Ing 3 i-t Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 PM 12.00 (PLEASE PRINT IN)NK OR TYPE ALL INFO RMATIOA9 Date: p City or Town of. NORTH ANDOVER To the Insp ctor 6f Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) &l yr&x� \ b we Owner or Tenant N, lAp,c.L *-r "mir" n 2 Qu 1 Telephone No. Owner's Address Noor� pm uE Is this permit in conjun tion with a buildinRy permit? Yes ❑ No KK (Check Appropriate Box) Purpose of Building &J'o UX r 1,;;e, 6JVyi j- Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters —47 New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of thefollowin table maybe waived by the Inspector of Wires. l' No.of Recessed Luminaires No.of Cell: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 mergency Lighting rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Detection and 7 No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. TotTons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained p Totals:I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security De Devi :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 Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Valueof lectr'cal Work: L�U� (When required by municipal policy.) Work to Start: �v S Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VE GE: 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,tinder thep ins and penalties of perjury,that the information on this application is true and complete. nn FIRM NAME- LIC.NO.: olt61 K Licensee: 3jZr \ Signature LIC.NO.: (If applicable,enter "exempt"in the license number line) Bus.Tel.No. Address: Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of ublic 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 waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PEXMlT 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 permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed 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 n Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ a Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass4 R Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: - 3- -i S" DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com Date.1/. .. ... O�r►ORny,� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING .+f `4•$ACMUg� This certifies that ..�.f..,L... . .7 :� �'-"j'�' V...........:.�..!../.. 1S��t�f _ haspermission to perform .......... . f .!. wiring in-the building of.......... ... �) .............. ../�......✓c- ,North Andover,Mass. 3 Fee ........Lic.No. . ! .................................................................................... ELECTRICAL INSPECTOR Check The Commonwealth of Massachusetts _ Department of IndustrialAccidents - W X Congress Street,Suite 100 ' d Boston,MA 02114-2017 www mass.gov/dia ,M . 5�• ' der /Contractors/Electricians/Plumbers. Workers,CompensationTO BE PILED WITH THE PEP'WT'T VG AUTHORITY- Please Print Le 'bl A ' licant Information Name(Business/Organizationftdividual)' Address: City/State/Zip: Phone lYJ.1 Are you an employer?Check the appropriate box: Type of project(required); 1.Q 1 am a employer with em to full and/or part-time).* 7. ❑NeVV�dbnstrUbtion P yees( 2•❑I am a sole proprietor or partnership and have no employees working for me in 8. F1 Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.E]1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my Property. 1 will 11.❑Electrical repairs or additiop.s ensure that all contractors either have workers'compensation insurance or are sole PXlnbing repairs or additions 12 proprietors with no employees. 5.FJI am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13•. Ro6£repairs These sub-contractors have employees and have workers'comp.insurance-t 14.Q Other 6.Q We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and"we have no empldyees.[No workers'comp.insurance required.] *Any applicant that chdoks box 41.must also fill out the section below showing their workers'compensation policy information: ork then hire outside contractors must davit indicating suc t'Homeowners who submit•this affidavit indicating they are doing all wmane name of the sub-contractors and state whether r or sa new,pot those ntN have h $Contractors that check this box must this an additional sheet showing employees. If the sub contractors have employees,they must provide their workers'comp.policy number. jam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Expiration Date:. Policy#or Self-ins.Lic.#: City/State/Zip: Site Address: o 'c number and a iratiou date). Job S (showing the policy gp Attach a copy of the workers' compensation policy declaration page(sh g p 0.00 Failure to secure coverage as required cx MGL ennalties2in the form of criminal TOP WORK ORDER and fine of up to $2500.00 a and/or one-year imprisonment,as well p be forwarded to the Office of Investigations of the DIA for insurance day against the violator.A copy of this statement may coverage verification. I do Hereby certify under thepains and penalties ofperjury that the information provided above is true and correct Date: signafore: Phone t official use only. Do not write in this area,to be completed by city or town official Permit/License# City or Town: Issuing Authority(circle one): ector 5.Plumbin Inspector 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Insp g p 6.Other Phone#: Contact Person: 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'deffited 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'orr•trusted 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 b6 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 iequdred." 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 oftbis 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 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 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 fel 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"fob 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 burn leaves etc.)said person is NOT requited 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-MASSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia M�oN. COMM• � ����o``'G w��G� ' 6t It �v4E silk, AC 0" OP ID:TD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 09121/2015 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(les) 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 DeSanctis Insurance Agcy,Inc. NAME: 100 Unicorn Park Drive PHONE pqX C No Ext): A/C No): Woburn,MA 01801 E-MAIL ADDRESS: PRODUCER CUSTOMER ID#:J U PIT-1 INSURERS AFFORDING COVERAGE NAIC# INSURED 142 Jupiter Lafayette R Inc. INSURER A:Harleysville Insurance 26182 al Lafayette Rd. INSURER B:Technology Insurance Company42376 Salisbury, MA 01952 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSRPOLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY1 (MM/DDNYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY SPP00000076460P 12/23/2014 12/23/2015 DAMAGE TO RENTEIT_ PREMISES Ea occurrence) $ 100,00 CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 5,00 X Contract L X XCUCotLiaab PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 3,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 3,000,00 POLICY 17X1 PRO LOC DEDUCT. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY(Per person) $ A X SCHEDULED AUTOS BA76461 P 12/23/2014 12/23/2015 BODILY INJURY(Per accident) $ PROPERTY DAMAGE X HIRED AUTOS (PER ACCIDENT) $ X NON-OWNEDAUTOS $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,00 EXCESS LIAR CLAIMS-MADE A CMB00000078286P 12123/2014 12/23/2015 AGGREGATE $ 10,000,00 DEDUCTIBLE $ X RETENTION $ 0 $ WORKERS COMPENSATION X WC STAT U- X OTH- AND EMPLOYERS'LIABILITY T RY IM ER B ANY OFFICEOPRIETEREXCLNE D?ECUTIVE Y/❑NN N/A TWC3442671 12/23/2014 12/23/2015 E.L.EACH ACCIDENT $ 1,000,00 (Mandatory in NH)and MA,ME,NH E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,It more space Is required) Replacement of Master Boxes at Four Sites-Fountain Drive-667-1 Bingham Wa -667-2 Foulds Terrace-667-3 O'Conner He' ht 667-4 North Andover MA 018y45 DHtD FISH#196040. "ADbITIONAL INSMESSS LIMATS ARE NO GRtATER THAN THOSt REQUIRED BY WRITTEN CONTRACT."Town of North Andover, North Andover Housing A thority and the De artment of Housin and Community Develo ment... CERTIFICATE HOLDER CANCELLATION NORTA-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Electrical Inspector ACCORDANCE WITH THE NY PROVISIONS. 1600 Osgood Street Bldg 20 AUTHORIZED PRESENTATI Suite 2035 '*4 North Andover, MA 01845 hxp- C 1988- 009 ACORD C RPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD NOTEPAD:/► , HOLDERCODE NORTA-1 -�' JUPIT-1 PAGE 0 G INSURED'S NAM Jupiter E p Electric, Inc. OP ID:TD Date 09/21/2015 (DHCD) are listed as Additional Insureds.