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Home My WebLink AboutBuilding Permit #274-13 - Suite 306 10/5/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: v Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Smoi' �1/1� C� _ _ -- DR nP_nnf PROPERTY OWNER K-CC;'- r� C? OV Z'''-"' Al, �—' Print 100 Year Old Structure yes; no. MAP NO: PARCEL:ZONING DISTRICT; Historic District no Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑Well ❑ Floodplain ❑Wetlands. ❑ Watershed District 0 Water/Sewer � �E$C� �,RIPTION OF WORK BE PERFORMED: Q Ide ficication Please Type or Print Clearly) OWNER: Nam�JJJJ0 �'J0 QJ'QCr,&K Phone: Address:Su%� 0 4 �rg10a i bel l\� �� p21 3 CONTRACTOR Name: 111 AM-- . Phone: L Address: Supervisor's Construction License: Exp. Date: 1� 2Dt'3 Home Improvement License: _ Exp: Date: ARCHITECT/ENGINEER 07-19W ` LS 5— Phone: 6 Address: 2103 (ol Ctz-U lO`LJ 4Reg. No. 16 be C7 FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. v C7 Total Project Cost: $ 2�'� O L FEE: $ ` Check No.: 0 � g Z&� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund !, ✓✓- S1 ✓��- ,SignatureM1of Agent/Owner gn_afure of contCactor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ i 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments conservation Decision: Comments ti• Nater & Sewer Connection/Signature& Date Driveway Permit DPW Town ]Engineer: Signature: Located 384 Os ood Street FIRE DEPARTMENT - Temp Dumps t n site yes Located at'124 Main Street- Fire Departimerit,siginaturb/date - ! i 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 NOTES and DATA— (For department use ® Notified for pickup - Date } Doc.Building Permit Revised 2010 . 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 NOTE: 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/Crossection/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 NOTE: 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 ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: 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: Doc.Building Permit Revised 2012 Location No. R 7 '" 3 Date e ` TOWN OF NORTH ANDOVER e ® y Certificate of Occupancy $ Building/Frame Permit Fee $T .--- ' , Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 28 25792 E�,dding Inspector C�U,�� Location No.o?74� Date J2/5/' 2"' g - TOWN OF NORTH ANDOVER . . . Certificate of Occupancy $ Building/Frame Permit Fee $ _ 3 4 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#11 2 11Z11 26017 Building Inspector • O r ^r ,SSACHUS CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 274-13 on 10/5/2012 Date: December 5, 2012 THIS CERTIFIES THAT THE BUILDING LOCATED ON 21 High Street Suite 306 MAY BE OCCUPIED AS a law office IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: RCG North Andover Mills LLC 21 High Street North Andover,MA 01845 Building In pector Fee: $100.00 Receipt: 26017 Check :1127 Stantec Architecture Inc. 303 Congress Street,6th Floor Boston 02210 Tel:(617)7)423-4223-42 52 Fax:(617)423-4333 Stantec December 5, 2012 File: Burt Hill/Stantec Project#218410083 Mr. Gerald Brown Inspector of Buildings Town of North Andover 1600 Osgood Street North Andover, MA 01845 Reference: Suite 306—S& U Office Space East Mills, North Andover Dear Mr. Brown: The tenant fit-out for Suite 306 located on the third floor of 21 High Street,at East Mills in North Andover, MA,was to the best of my knowledge, belief,and understanding,constructed in conformance with the construction documents issued for building permit dated October 5, 2012, Permit#274-13 in accordance with 780 CMR Commonwealth of Massachusetts building code. During the course of construction, representatives of our office made periodic visits to the site to observe the progress of the work. Respectfully, STANTEC ARCHITECTURE INC. Digitally signed by linda. l l n d a. smiley@stanteccom smiley@stantec.com DN:cn=linda.smiley@stanteccom Date:2012.12.0709:40:04-05'00' - Linda Smiley Senior Associate Tel: (978)270-3203 Linda.Smiley@stantec.com c. Keiran Whelan Dave Steinbergh Iss documentt NORT1y Townofndover 0 . "i" . . V, No. - M!" - y � o �Z Y O LAK• h ver, Mass, _ COCKICM/W3[. ��• A�RATEOT T L D S U BOARD OF HEALTH PERM, I Food/Kitchen Septic System THIS CERTIFIES THAT .... ... . .. .. ...1 Y: .::a:. ...��.� G?4: °:.. �.��. .... ................................... BUILDING INSPECTOR ion has permission to erect................... ....... buildings on --Ql...,�I..��.1�..��..................................... Foundat. ou / l to be occupied as ... ...�A?;:;c.. ...,�. .5,0.... ...... CJ.t.: t .> ?............ .�?.:... ....: �h" Chimney„ provided that the person accept ng this permit shall in every respect conform to the terms of thea licationi 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 ELECTRICALINSPECTOR UNLESS CONSTRUCTION ST RTS iJ- Piz + ...................... Service 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. Smoke Det. SEE REVERSE SIDE Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 32,302.60 m $ - $ 387.63 Plumbing Fee $ 48.45 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 48.45 Total fees collected $ 584.54 21 High Street 274-13 on 10/9/12 Tenant Fit Up NORTH Town -o 2 s E : 1,. n over �. - 0 No. o �wN, h ver, Mass, A- c0c.41 M .". 7� A A�R 'rED s U BOARD OF HEALTH Food/Kitchen PERMI-T T LD Septic System / THIS CERTIFIES THAT ....�.�.�..�..�...,lY:5':".t�2..::��1�p4:�:..�c.��.,�....4.��............................. BUILDING INSPECTOR /— Foundation has permission to erect ...........Kngtihis ....... buildings on /..... . ..��. . ... (! ......................................... Rough to be occupied as ... ...C��??x. �.. . .i„l�f. ....... CJ..� F.. ........`... .1�.:... ....:-S'C9��h Chimney provided that the person accept permit shall in every respect conform to the terms of thea lication 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 ST RTS Rough �j Service ...................... ..... r"~~'.......................... 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. Smoke Det. SEE REVERSE SIDE Smolak&Vaughan Move: Estimated Cost Schedule of Values 10/1/2012 General Conditions $ 1,000.00 Demolition $ - Carpentry $ 3,200.00 Drywall &tape $ 4,500.00 Prime and Paint $ 3,860.00 Materials: Framing, Drywall and Glass $ 2,500.00 Flooring $ 4,500.00 Custom'Woodwork $ - Cabinetry&Countertops $ - Plumbing $ - Sprinkler Work $ 1,800.00 Electrical $ 3,656.00 HVAC $ 3,350.00 Cleaning&dumpsters $ 1,000.00 Sub-total $ 29,366.00 JK Construction $ 2,936.60 Total $ 32,302.60 Plus Building Permit $ 396.00 t Massachusetts- Depai-tment of Public Safet} Board of Building Re!,lulations and Standards Construction Supervisor License License: CS 66334 — --- KIERAN T WHELAN , 31 RICHMOND ST WEYMOUTH, MA 02188 Expiration: 9/26/2013 Commissioner Tr#: 6168 ....w - " _�i1:e-f°om�nanu�ea/.� o�.�iraoctclu�aelta Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR., Registration: .=171393 Type: Expiration 3115/2014 Individual c KI E N WHELAN KIERANWHELAN =3 31 RICHMOND ST WEYMOUTH,MA 02188 Q=- Undersecretary OFFICE OF BUILDING INSPECTOR 3? ° TOWN OF NORTH ANDOVER CONSTRUCTION CONTROL PROJECT NUMBER: 218410072 PROJECT TITLE: 3rd Floor, Suite 306 PROJECT LOCATION: East Mills, Water Street, N. Andover NAME OF BUILDING: Building 1. 3rd Floor NATURE OF PROJECT: Corporate Fit Out IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUILDING CODE, 1,_Lin_da_S. SMUeX REGISTRATION NO. 1 QQRO BEING A REGISTERED PROFESSIONAL ENGINEER/ARCHITECH HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS CONCERNING: ENTIRE PROJECT ❑ ARCHITECTURAL STRUCTURAL ❑ MECHANICAL ❑ FIRE PROTECTION ❑ ELECTRICAL ❑ OTHER(SPECIFY) FOR THE ABOVE NAMED PROJECT AND THAT,TO THE BEST OF MY KNOWLEGE, SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS STATE BUILDING CODE,ALL ACCEPTABLE ENGINEERING PRATICES. AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. 1 FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND B EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED 1N SECTION 116.0 1. Review, for conformance to the design concept,shop drawings, samples and other submittals rjw ' are submitted by the contractor In accordance with the requirements of the construction W. d ments. t le and approval of the quality control procedures for all code-required controlled materials. �I e nt at intervals appropriate to the stage of construction to become,generally familiar I he progress and quality of the work and to determine, in general, if the work is being armed in a manner consistent with the construction documents. a a NT TO SECTION 116.2 .2 !SHALL SUBMIT WEEKLY, A PROGRESS REPORT A ER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING INSPECTOR. w f MPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE �x CTORY COMPLETION AND READINESS OF THE PROJECT FOR OCC PANCY. all IGNATURE S SFCRIBED AND SWORN TO BEFORE ME THIS ,_DAY OF -- }A / NOTARY PUBLIClaeo MY COMMISSION EXPIRES �. �n o ve Y The Commonwealth of Massachusetts Department of Industrial Accidents Office 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): 1`r qy1A al-I.(,tU Address:CZ C\(Akata d $ City/State/Zip:�15tTAq J� �A OU'CS Phone#:—%a 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 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. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I 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 required.]f employees. [No workers' 13.n Other comp.insurance required.] 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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. kContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. Cam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. (� l :assurance Company Name: `MPJ \ 4 trTuYlF ` ?olicy#or Self-ins.Lic.#: �•L [� d — 0 I Expiration Date: 1 lob Site Address:_ Gc► N A 0 Q)N-ti-. City/State/Zip: k,ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ,ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 )f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certi under the pains andpenalties ofperjury that the information provided above is true and correct. ;i nature: Date: t ® l L--� 'hone#: 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#: i I 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 of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)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 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/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 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 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 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 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE [devised 5-26-05 Fax#617-727-7749 www.mass.p-ov/dia C L'►laVWaO S".dx3 UC"SIURWO AIR f�ig�JSS1iiI�1i7601N1o0lti0it�000) ai, , D!m �A�+OiWolOo�ae G �. I �-�Rt, ��.�-�- i � /' ' � _, 7� ,f � r 4 I f Date.....J...17.9to........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING HU DThis certifies that ............... ..... .... ............... .... has permission to perform .............. ...... ................. .... .... ...... ...... wiring in the building of.......R..c......G ......... ......... .................... ..... ........ ;9*,***,***...- ....... .. 5��4..........................3 ...... ............... . . North Andover,Mass. Fee..17 ..............Lic.No. -1 Check# 91 is M` Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked a 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(NEC),527 CMR 12.00 (PLEASE PRINT INNK OR TYPE ALL HFORAMTION) Date: 5/.i1 A'S City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the el octricaI rk described below. Location(Street&Number) ��T/ 1 Owner or Tenant 1' Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ),LJ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Aa A Location and Nature of Proposed Electrical Work: Completion of the following 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- El o meLighting r rnd. rnd. Satter Units No.of Receptacle Outlets ' No.of Oil Burners FIRE ALARMS No. of Zones flo.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Dis osers HeatPump Number Tons KW No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P g Connection No.of Dr ers Heating Appliances KW Security Systems:* Y No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Bathtubs No.of Motors Total HP Telecommunications Wiring: No.Hydromassage No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: /�� (When required by municipal policy.) Cork 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 1A' BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and naltiees of per'ury,�tZat the in nation on application is true and complete. FIRM NAME: �l/ {� LIC.NO.: Licensee: Signature LTC.NO.: (If applicable,enter "ex rcpt"in the ice se numbe ) Bus.Tel.No.: Address: t .y Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department ub is Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Li ensee 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: $ _71 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 r 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. ERule ermit/Date Closed: ***Note:Reapply for new permit ❑ tension Act—Permit/Date Closed: Trench Inspection Pass 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 GH INSPECTION: Pass-? Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH PECTION: Pass Failed Re-Inspection Required($.) ❑ f` Inspectors Comments: p- ' Inspectors Signature: /,ry `� r � �y., Date: 2- 3 fes' FINAL INSPECTION: Pass Q Failed Re-Inspection Required($.) ❑ nspectors Comments: 3� Inspectors Signatur Date: :13 WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com f The Commonwealth of Massachusetts - - tria Department of Indus .l Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: �✓"GiZ �� City/State/Zip: )V&4�/,� �� Phone Are you an employer?Check the appropriate box: Type of project(required): IAI am a employer with � 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 7. 2.❑ I am a sole proprietor or partner- listed on the attached sheet. Remodelvng ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions and we have no c. 152 1 4 12. Roof repairs myself.[No workers comp. 0 p o workers insurance required.]t' employees.[N 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they a-re doing all work and then hire outside contractors must submit a new affidavit indicating such. tColtractors 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 infbrmation. R TZ- Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 7/ K/ 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 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 Ap to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under tltams andpenalties ofperjury that the information provided above is true and correct. Si ature: Date. Phone#: v/�O 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#' 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 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 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 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/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 of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is 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 ofMassac 1,usPtts Department of l dustrial Accidents Office of Investigations 600 Washington Street Boston MA 02111 Tel,#617-727-4900 ext 406 or 1.-877.MASSA E Revised 5-26-05 Fax#61.7-727-7749 www-mass,govldia -,cbMMONWEALTH OF MASSACHUSETTS ASA REG JOURNEYMAN -ELECTRICIAN ISSU,. ES THE ABOVE'LICENSE 70 YO.UNG ::& SON ELECTRIC CO. MIR SLAV MLADY_. �:.) 62 N0RF0LK ;STREET m' CAMBRIDGE MP 02139. 2622•; 2426 f833830 s i COMMONWEALTH OF MASSACHUSETTS ,I -. • • } RI=G)S EKED MAW ME ER,ELECTRtCIAttJ ISSUE�li E ABgy LICENSE TO; 3 ! { YbUNG $� .SON UE,0 BRIG CO a MT}RO�SLAV€ S MLAY° �' j 6�', NORFOLK A¢T�E,�rt hs �a121 r ,CA1�2rDE M ,� Of39 262 ` 3847 1 A i j• }