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HomeMy WebLinkAboutMiscellaneous - 1 Sandlewood CircleDate.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .6m OL A# ..... F / . P ......... ... has permission to perform ...... P..,,*. .... W .... C—. /t ...... wiring in the building of . fl'vuz-.-Y.444��. ...... 77. .... 57 ................ . North Andover, Mass. Fee.-,�5'01."'L Lic. No..11�44 ........ Check# 6477 J� 3 The Commonwealth of Massachusetts Office Use Only �Permit No. 7Z Department of Public Safety Occupancy & Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts -Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) City or Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Date February 24, 2006 To the Inspector of Wires: Location (Street & Number) 2357 Turnpike Street Owner or Tenant Valley Realty Development LLC Owner's Address 2357 Turnpike Street, North Andover, MA Is this permit in conjunction with a building permit: Yes[K] NoF� (Check appropriate box) Purpose of Building Pump Station Utility Authorization No. 161228 Existing Service New Service Number of Feeders and Ampacity Location and Nature of Proposed Work 100 Amps / Volts Overhead UndgrndF—J No. of Meters Amps 120/208 Volts Overhead Undgrnd X❑ No. of Meters 1 341, 146 gnd Furnish and install Power for Pump Station No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above in - and and Generators KVA No. of Receptacle -Outlets No. of Oil Burners Unitsf Emergency Lighting Battery No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total tons No. of Detection and Initiating Devices No. of Disposals Heat No. of Pumps Total Total Tons KW No. of Sounding Devices No. of Dishwashers S ace/Area Heating P 9 KW No, Self -Contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local Munic. Conn. F1 Other No. of Water Heaters KW No. of Sins No. of Ballasts Low Voltage Wiring No. of Hydro Massage Tubs No. of Motors Total HP Other: 'INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws: YES ❑ NO ❑ 1 have a current Liability Insurance Policy Including Completed Operations Coverage or its substantial equivalent. YES ® NO ❑ I have submitted valid proof of same to this office. If you have checked YES, please indicate the type of coverage by checking the appropriate box: INSURANCE [21 BOND❑ OTHER❑ (P/ease specify) Carlin Insurance Expiration Date Estimated value of electrical work $ $150,000 (Total Const. Cost) Work to start Immediately Inspection Date Requested: Rough will call Signed under the penalties of perjury: FIRM NAME Consolidated Electrical Services a division of Licensee Lawrence Pantano Signature Final will call LIC. NO. 17502A LIC. NO. Same Address 661 Pleasant St. Norwood, MA 02062-4603 Business Telephone No. (781)-769-7110 Alternate Telephone No. (800)-628-7110 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or it's substantial equivalent as required by Massachussets General Laws, and that my signature on this permit application waives this requirement. ❑ Owner []Agent (check one) (Signature of Owner or Agent) Telephone No. Permit Fee $ 225.00 $ 9994 Date ... : �. — 7— 4 /—. �//.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING that ................................... P ...... ........................................ This certifi A;1-� �,� has permission to perform ....... 1?;It .................. .. ............. ... ........ ..... .. wiring in the building of ....... twa:�5 ) -r/ b,6L--z,- ............................................................................ at ..... ................. .. ISorth Andovei, Mass. FeeS ... Lic. No. ........ - Z �,C;z 1; � i� �C� iL Check # 91 6 6-> .<; Commonwealth of MassachusettsFrRe Official Use Only Department of Fire Services ,�BOARD OF FIRE PREVENTION REGULATIONSnd Fee Checked (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 IN INK OR TYPE ALL INFORMATION) City or Town of: NORTH ANDOVER By this application the undersigned gives notice of his or her inti Location (Street & Number) Owner or Tenant M cs ` T, Owner's Address fi)0 AIVA Date: _ To the Inspector of Wires: to perform the electrical work described below. A Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No. (Check Appropriate Box) Purpose of Building C��(/i C Utility Authorization No.—I a 7 o S / © 0 Existing Service Amps v Volts Overhead ❑ Und rd g ❑ No. of Meters New Service /G® Amps LA / L�, MV01ts Overhead ❑ Undgrd � No. of Meters / Number of Feeders and Ampacity 11210 p 4114 0 T Location and Nature of Proposed Electrical Work: CrvI( Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: j ( 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 prbvides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove age is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the naltles of perjury, that tl e i fo ation on tltis application is true and complete. FIRM NAME: leC7)-/ LIC:NO.: (j �d Licensee: lV �./ f ( " Signature (Ifapplicab e, enter "exempt" ih the license number line.) IC. NO.:� Address: Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. Lic. No.�-7�'-`��� OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ Com letion of thefollowing table may be waived by the Inspect 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 Above El In o. o mergency ig hng rnd. rnd. Batte 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 No. of Ranges No. of Air Cond. TotaTons Initiating Devices No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW Totals: No. of Self -Contained No. of Dishwashers Space/Area Heating KW Detection/Alertin o, Devices Local ❑ Municipal ff Other No. of Dryers Heating Appliances Kir Connection Security Systems: No. of Water' No. of of No. of Devices or E uivalent Bal Si ns Ballasts as ts Data No. Hydromassage BathtubsNo. of Motors Total HP No. of Devices or E uivalent Telecommunications Wiring: OTHER: No. of Devices or E uivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: j ( 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 prbvides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove age is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the naltles of perjury, that tl e i fo ation on tltis application is true and complete. FIRM NAME: leC7)-/ LIC:NO.: (j �d Licensee: lV �./ f ( " Signature (Ifapplicab e, enter "exempt" ih the license number line.) IC. NO.:� Address: Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. Lic. No.�-7�'-`��� OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ELECTRICAL PERMIT NO. INSPECTION ELECTRICAL INSPECTOR - DOUG SMALL REPORT: Y 1?(1T7!'� 77TOnT nmr�i.T_ Passed — j ] Failed — Inspectors' comments: I (Inspectors' Signature - no - 2. o2. FINAL INSPECTION; Passed — j 'j Failed — Inspectors' comments: (Inspectors' Signature - no r IS) Date Re -inspection required ($50.00) Date LA -INSPECTION — SERVICE: DATE CALLED NATIONAL GRID: Passed — [ ] Failed — [ ] Inspectors' comments: (Inspectors' Signature - no �� Date u\ur a l.11l➢1V - V'JuM R: Passed — [ ] Failed — j ] Re -inspection required ($50.00) Inspectors' comments: (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE FdI,LED OUT AND LEFT ONSITE IF THE AREA TO BE JNSPECTED YS NOT ACCESSIBLE ANDA REINSPECTION OF $50.00 IS TO BE CHARGED. .J 0 q. 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):_ Address: City/State/Zip: (P C 7-/`/ c T ,V1 Phone #: � % d,o ( l^ .-f 6 Are you an employer? Check the appropriate box: 1.25 I am a employer with_ 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We ate a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other • uv "rr=L—L< <uaL uox ff t must also 1111 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. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: iG/`-o%L✓t✓cc/! C/^�f Ci/State/Zi : / City/State/Zip: p ,L /7+A/V`t 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 certolnder t�ns and penalties ofperjury that the information provided above is true and correct. Si nature: Date: a / Phone #: ,C l p2 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): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: f ^ V 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 t 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, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia