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Home My WebLink AboutMiscellaneous - 1 MCCABE COURT 4/30/2018W 2 4 1/1 S Date ....... 7/ �/- TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... e- r.1 4 . .............................. ;�f ........................... has permission to perform ... k -A. 0. .................................................. wiring in the building of ........ A ....... H.. .14 .............................................. ..... ... ...... at ..... M. ....... Q .................................... . torth,Andover M ............. !;;r .. ........ Fee. Lic. No. ............... I �EiiCAL MpEcmlk "I Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer THE COMMONWEALTH OFh14SS4affJSE77S Office Use=�� W DLPARTJfiM0FPUB0CS4FL7Y Permit No. BOAMOFFMPREYFV77ONREGUTA7YONS527G7NR1Z- Occupancy & Fees Checked M APPLICATTONFORPERAIRTTOPERFORMELE=CAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat4 / "A a2Al0 Town of North Andover To the Inspector of Wires: The undersigned applies for a pemut to perform the electrical work described below. AP PARCEL Location (Street & Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Purpose of Building , P."� o o r.-. e144 Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Yes No u (Check Appropriate Box) Overhead Underground Overhead Underground Utility Authorization No. No. of Meters No. of Meters No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground and No. of Receptacle ets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Bumcrs FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW Y.r 313k iV No. of Self Contained 2�r Detection/Sounding Devices Local Municipal prat M Other No. of Dryers Heating Devices KW ' / Or. No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP 1 i.. III':• . I . / ..' .' `:1 - . I � II �" i � �� , • O .1....,1:11' .• WorictoSW 10.:.1.. till •:. :�`I:. I li 9a ''P* FF� �'''t"""""'Dale ValuedEkcbCal Wodc $ Ra# ` L/ 6 >{mal A d� lJkf&j, a'loe0 AkTe1Na OWNERSk4SLRANCEWAIVEP,IamawarethattheL=wdoesmthawedicumsmoeoataaWcritsst>lmat iale4ukalilasregmedbyMissad�Cvnc2lLaws ardthatmymgxaw ndwpmitapp)icatimwtitrsiwregairaanat / (Please check one) Owner a Agent Telephone No. PERMIT FEE $ VVV Signature of -Owner or Agent Date ......... /.� ..... ............. TOWN OF NORTH ANDOVER 0 6. , PERMIT FOR WIRING 40 This certifies that ........ C-�, ..................................................................................... has permission to perform-��... �n ............................................................... wiring in the building of ...... ....................... ....... at ... .... ........................... ..... . North Andover, Mass. ... ........... Fee..Y� .. ......... Lic. No. . ........... ............ Ch . eck # ELEcTRicAL i PE#/, 6 4 �, / Commonwealth of Massachusetts lugDepartment of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use" Only Permit No. �9 Occupancy and Fee Checked [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 PRW EV INK OR TYPE ALL INFORMATION) Date: lr l y _G -;/ 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 electrical work described below. Location (Street & Number) Owner or Tenant il Ti, Telephone No Owner's Address Is this permit in conjunction with a building permit? Yes ❑ Noe'E] (Check Appropriate Box) Purpose of Building - Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters New Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters Number of Feeders and Ampacity Loca ' and Nature of Proposed ElectricalWo k: -- Lf �� Completion o the followin table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No• of Total No. of Luminaire Outlets No. of Hot Tubs Transformers KVA Generators KVA No. of Luminaires Swimming Pool Abovd• Ele In- o. o mergency ig 0 d. 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 an No. of Ranges No. of Air Cond. Total Initiatin Devices ITons No. of Alerting Devices No. of Waste Disposers . Heat Pump I Number Tons KW No, of Self -Contained __..._ _._.. ....._. _. _ ...._ Totals: _. Detection/ ces No. of Dishwashers Space/Area Heating KW cip Other Connection No. of Dryers Heating Appliances KW Security , No. of WaterNo, Nf o. oNo. of of Devices or Equivalent Data Wiring: Heaters' Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total Hp llelecommun6cations icing: OTHER: No. of Devices or Equivalent Attachadditional detail if desired, or as required by the Inspector of Wires. Estimated Value of El c 'cal W rk: .(When required by municipal policy.) Work to Start: Z / LJ Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO 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 cerZ=7) e is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE:OND ❑ OTHER ❑ (Specify:) I certify, under the p nal - of perjury, that the information o this plication is true and complete. FIRM NAME: L' /,� D S �� e �(` �„v LIC. NO.: 7 Licensee:%pyla Signature LIC. NO.: (If applicable, enter "exempt " in the l' ense num er line.) / Bus, TeL No.: -SSD X9473 Address: 5--1,041A0 — - tc U Z 4 / Alt Tel. No.: 6/ -1 y -t ?� *Per M.G1 c. 147, s. 57-61, security work requires D artment of Public Safety "S" License: Lic. No. OWNER'S INSURANCE R: I am aware that the Licensee does not have the liability insurance coverage normally required by law. y s' a below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. KI.,? f- PERMIT FEE: $ gS- / The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 i' j www.rszassgov/dia Workers' Compensation inselu-ance Affidavit. Builders/Contractors/Eiectricians/Pfambers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: oZS City/State/Zip: Q, Phone #• Are you an employer? Check the 21mropriate box: l� i am a employer with 4. ❑ I am a general contractor and I Type of project (required): employees (full and/or part-time).* 2. ❑ I am a.sole proprietoror partner- have hired the sub -contractors listed on the attached sheet t 6. ❑ New construction 7• ❑ Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition' working for mein any capacity, [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its g El Building addition required.] 3.0 I am a homeowner doing all work officers have exercised their right of eemption per MGL otrical repairs or additions 11.7 Plumbing repairs or additions myself. [No•workers' comp. c.. 152, 51 (4),'and we have no 12.❑ Roof repairs insurance required:] t .employees. [No workers' 13.❑.Other comp. insurance required.] + -rr•• - t •• �•a• Wye OUX ifa musk also nu out the section below showing their workers' compensation poi icy information Homeowneta who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. �Contmetors that check this box mustattsehed an additional sheet showing. the name of the sub -connectors and their works' comp. policy information. I enc an employer t"at.is proved g:workers c inforryWIDn. Insurance Company Name: nV employees: Below is the policy and job site Policy # or Self -ins. Lic. #:_ 6�& FZ_,3 FQ 1 )9 � EXpiration Date: e� Q Job Site Address:_ �% G �/� %� G / - Jyl%�s ��/I/ City/Statezip: /l/ g, LAO , eAL_ 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 ce * u erL ai d penalties of perjury .ttYat the information provided ab o a is grue and cotter Si atwe: / Date: �l g Phone #: b l S9 Ll f' Y 3 770fficiatly. Do not write in this area, to be completed bycity or town official Permit/License # ity (circle one): lth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 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 presentad 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 atiidavit. The affidavit should, be returned to the city or town that the application for the permit or license is being requested, nofthe 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 f ft= permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, N A 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-77451 www.mass.gov/dia