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HomeMy WebLinkAboutMiscellaneous - 10 OLD CART WAY 4/30/20182743 Date ...... ... .... V. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... .4 ..... D.T ....... ..... .............. has permission to perform ............... . ................. wiring in the building of ......... ........................................... o I A ('r at ..... .................. .......... . North Andover, Mass. .............. Fee .. ........ 0.0... Lic. No. ............ ... ECTRICAL INSPECTOR ( �� 1010a14 35. 00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File :Y of 4f of M3,001tr4uutto Department of Public §�afetg BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Office Use Only Permit No. Occupancy & Fee Checked 3190 (leave blank) Ward Area APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WOR All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE Al L INQRDM�ATT ONI Date City or Town of AN / �' To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street &Number) D Owner or Tenant L e L- l E L Owner's Address Is this permit in conjunction with a building permit: Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps _I Volts Overhead ❑ Undgmd ❑ No. of Meters New Service Amps _� Volts Overhead ❑ Undgmd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Installation of alarm system No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above tn gmd. ❑ gm -d- ❑ _ n Generators KVA 4 No. of Emergency Lighting No_ of Receptacle Outlets No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained No. of Ranges Total No. of Air Cond. tons No_ of Disposals Heat Total Total No. of Pumps Tons KW No, of Dishwashers Space/Area Heating KW Detection/Sounding Devices LocalMunicipal ❑ Other ❑ Connection No. of Dryers Heating Devices KW No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring u �� Total HP 1--7 No. Hydro Massage Tubs No. of Motors LRE OTHER: 4 / qDr-VJCG5 - l/VCLaA 19MO&E beT6�;fP- INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy includ- ing Completed Operations Coverage or its substantial equivalent. YES O NO O 1 have submitted valid proof of same to the Office. YES O NO O If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE M BOND. O OTHER O (Please Specify) (j�� /( (Expiration Date) Estimated Value of Electrical Work S - iE�-/ r 60 Work to Start �l ��(� inspection Date Requested: Rough Final Signed under the Penalties of Perjury: FIRM NAM LIC. No. 2 3 1 C i Licensee Signature IC. NO. Bus. Te. No. 7-431-580 J Address 60 William St./Wellesley[, MA 02181 Alt. Tel. No. — 1-9837 OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement- Owner Agent (Please check one) Telephone No. PERMIT FEE $ r v (Signature of Owner or Agent) .} y{ •• Nodi)►. kispeeior for rough andfar fkial,lnspeotiow: Permit must be obtekwd before oomamx* g any, and all work in complianoe with GA -C. 141 & all app)'ica- .i1..r...S-Aln bur�IC-n..Annvase is .n...iw�snA'•«..rnra�n.vr' ... r, v::'... re . il..c:. ..::..: ,, .- :,. ..'. .'. .. ..- .. -.. .. n z n n -171 Z5 rn c-�) O -v v z I L �n M rn O Da C-3 O v R O m m Z: 1 m r— m n n a z n O v 7; .4 Date... 803 NOW TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .J () ......... ck-ecAl-r- CO. ......................................................... has permission to perform ..'s e. ......... Q.tp;A, �.'. & ...................... wiring in the building of ..... CCLJ..(,�y ..... ............................... M at .... /6 .... 61j ... C ��Y. ......................... . NorthAndover, Mass: W Fee ... d .... Lic. No.411le ................ iiLi;��WC-A-L-i N**S'P'*E* C**T* 0**R'* 0 1-t 63� WHITE: Applicant CANARY: Building Dept. PINK: Treasurer The Commonwealth of Massachusetts Department of Public ScfetV BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 1200 Office Use Only Permit No. Occupancy & dee Checked 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK AU work to be performed in accordance with the Ma"achusetts Electrical Code, S27 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORHATION) Date City or Town of K 0 VUV_ r To the Inspector of Wires: The undersigned applies for a permit to perform the electrical ,work described below. Location (Street & Number) O L 'j7 � f-� Id- '\ —*— I C> u i Ocrer or Tenant Owner's Address V'znm Is this permit in conjunction with a building permit: Yes ❑ No 197— (Check Appropriate Box) Purpose of Building 9114- S'110'6' -)C_ Utility Authorization NO Existing Service __Zoo Amps 1 N / z-ZA=; Volts Overhead ❑ Undgrd New Se. -vice •1mps_� / Volts Overhead ❑ Undgrd ❑ Nuv.ber of Feeders and Ampacity Location and Nature of Proposed —Electrical Work No. of Meters 1 No. of Meters UN�D yr C, r,or..�n �I�ot4 l�a'yyC- l t/ t YLcA_ LSO w ✓kS C. v t� �1- Z 5 No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA _ No. of Lighting Fixtures Swimming Pool Above ❑ In- ❑ grnd. grnd. Generators KVA No. of Receptacie Outlets No. of Oil Burners (Batte N^- er EUnir s.nc'y Lighting •Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Total No. of Ranges No. of Air Cond, tons Initiating Devices No, of Sounding Devices No. ec Self Contained Detection/Sounding Devices Local ❑ Municipal ❑ ocal Connection Other No. o� Disposals ` p � No. of Peat Total Total Pumps Tons KW No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KW No. of Water Heaters KW No, of No. o Si¢ns Ballasts Low Voltage Wirinz _ No. Hydro Massage Tubs INo. of Motors' Total HP - .— MAR_!_ - w INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws h_-vc 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. YDS � No L� If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE n BOND n OTHER � (Please Specify) Expiration Date) Estimated Value of Electrical Work S Work to Start hl kLA-- C.,/�t,u_ Inspection Date Requested: Rough Final W (" _ C.r/l-t,c_ Signed under t�h/e penalties of perjury: "- FIF-4 NAME__ V b L -K c_tZt L_ _ �u�'li/dwc% //JJ LIC. Licensee ��&&3 tJ - ? 1 v Fit S Signature � ,�- /( LIC. NO. S pq-t4tLF_ Address" �� R - y-\9 164,,. vA i � 1�)O\Z1l� �V-A01ut. vit(/2— Bus. Tel. No.����� � ! V—)) z Alt. Tel. No. OSdNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit applicatio Waives h s requireme t. Owner Agent (Please check one) Telephone No. 600?- da� PERMIT FEE S ©� Si re of Owne - —TIO Cu nJ W V -t,-, "." Imo. (y(, 6+t 5� C� Gj , t,9,,..,� �� o (gY S Date TOWN OF NORTH ANDOVER jr PERMIT FOR PLUMBING This certifies that . . " /,-, '� .......................... ................ 9' has permission to perform ...... plumbin g in the buildings of ... J.'! ................. at. ...... North Andover, Mass. Fee. Lie. No.. ...... L �-�L- U. M-B-ING INSPECTOR Check # �'-' � 6 — , "- 'J, r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) �h ass. Date Permit # Building Location --/A Own is Name CJL 1✓/ ` J'P / E 9 7 g ^� �_��/� Type of occupancy Residential It New ❑ Renovation ❑ Replacement 99 Plans Submitted: Yes ❑ No ❑ FIXTURES t Installing Company Name Heritage Htg . &P_lg . Co- Inc. Address 35 Pleasant Street Stoneham, Ma 02180 Business Telephone •. 781 4 3 8— 7 7 7 6 Name of Licensed Plumber Gordon Switzer Check one: IX Corporation ❑ Partnership fl Firm/Co. Certificate 714 INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ® No ❑ If you have checked yes• please Indicate the type coverage by checking the appropriate box. A liability insurance policy 3 Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware. that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all . pertinent provisions of the Massachusetts State Plumbing C54a and Chapter 142 Mhe Genefal ws. By Sign ure of LicemiedPlumber Title Type of License: Master [X Journeyman ❑ City/Town f3 3 2 2 APPRCNE O O License Number %" Watts 9D bfp on water line to water boiler --- z Z cn X v' U) in O Z h0 .� rU r W tn X J N a . a h a z _ o C7 z a u�tr ��il cn z o1 a rr _ +� i� OU. J N W Cr. N w w S: [[: r ; W N Z �- C 0. S (J W O D W w d N cc w n C 2 J _ a O LL w a 3 3 O T Y a o h Z Y `( w w X 1x�{ii ;ix,.at{ r a U r 1„• O = `r' e. � N a r 0 Z O .O N a¢ —— w o r a O o r� a i, -F� i -1� " 3 Y a J a C[1 x N — C] a J 3 = a r -J a V J a 3 LY a1 �$ SUB—BSMT• BASEMENT IST FLOOR 2NOFLOOR `DRD.FLOOR �' 4TH FLOOR STH FLOOR 6TH FLOOR TTHFLOOR STH FLOOR t Installing Company Name Heritage Htg . &P_lg . Co- Inc. Address 35 Pleasant Street Stoneham, Ma 02180 Business Telephone •. 781 4 3 8— 7 7 7 6 Name of Licensed Plumber Gordon Switzer Check one: IX Corporation ❑ Partnership fl Firm/Co. Certificate 714 INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ® No ❑ If you have checked yes• please Indicate the type coverage by checking the appropriate box. A liability insurance policy 3 Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware. that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all . pertinent provisions of the Massachusetts State Plumbing C54a and Chapter 142 Mhe Genefal ws. By Sign ure of LicemiedPlumber Title Type of License: Master [X Journeyman ❑ City/Town f3 3 2 2 APPRCNE O O License Number %" Watts 9D bfp on water line to water boiler --- . . I 0 O. UA UA cc 0 0 CL 10 cc in 'IL O 0 0 Lu LL L6 0 .0. W. cc CL 0 cc LLI 0 U. 3.' 0 A 0 w G1 4c w uj U. . . I 0 UA CL 10 ul t 4 287 0� TOWN OF NORTH ANDOVER PERMIT FOR WIRING -T/f/pm S /--C- 0 .............................. This certifies that .................................................... has permission to perform.0u. wiring in the building of ............... &.� ... ................................ at ......... 10 ... ................ . North Andover, Mass. Lic.No.3;?t97E- ..... ...................... . . . ....... . ....... .... �f�6� ELECTRICAL INSPECTOR Check # do A .t Official Usc Only :,�,.m-� t�aleemonruaa+�tJe n� i�raaautcfivaell'a � Z Permit No. ,,,,�.J�aPar,imnn�� o� �irro �aruict,a Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. l I/991 (lcavc blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perforated in accord:Mcc with the iVtassaehUseus Glvclrical Code (: 527 CNIR 12.00n )4?1tC: (I'MISE 1GitltvT /tv INK O/i rr/�l. A I INF�Ol itL iT nr) / o��'Q 5 City ow "1'a�vtt of: To the Itlspeclol' of 1+71 -as: By this application lite uttdersigne gives nottcc of usgr her inlenti tl to perform the elccn ical work described below, _/ fl A! _ — f . /nn. L.ocitlolo (Street & Number) Owner or ').'enant Owner's Address Is this pertrtit lot conjuuctio!► with a Iauilding perneil? N es U I'ur lose of lluilditcgd 5 Ld-e4 C e Telephone No. No Ljenf'' (Check Appropriate Box) Utility Authorization No. i Existing Service .....�— Amps / Volts (3�erlac:rd ❑ New . ervice Anips / O'ulte Ovcricca<l ❑ Nulttbt't' of k'eerlers and Anoiaacity���^ Loentiuli and Nature of Proposed Electricalork: IA j� Undgrd ❑ No. of Meters Undgrd ❑ No. of Meters [vllu�rin ruble n,aY be :raivcd by the Ins cera of [trier OTi-lER- Attach addilional detail if desired, or as required by the luspector of [Mees. INSURANCE COV EItAAGE.: Unless waived by the owner, no permit fur the performance of electrical work may issue unless the licensee provides proof of liability in ance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cover, is in force, and lass exhibiled. proof of sante to the permit issuing Offic�'- CHECK ONE: INSURANCE 13�ND 0 OTHER [] (Specify:) Y (Expiration Date) E=stimated Value of Electrical Work: �� (When required by ntuuicipal policy.) work to Start; D 111spections to be requested in accordance with 1VIEC Rule 10, and upon completion, / cc�rtijj, ululcr the' l,aitr ll{crralttrs ujl,,�,jlr , rl,ur etre til »,a,inrr n» this application is trite and completa. i� I1t,11 NAnII:: f .%%%_... �--P °�r� r- 4 LIC. NO.: Signature (lf applicable, seer ..scarp[" Err the license nrrluber tin 1 Address: 1 l �a _ �� �! %� r%th 0WNERt'S I 1 :1NCk 1 41 VE It: am a%varc° that the Li doe required by law. Dy my signature below, I hereby waive this requircmcn Owneri'A ;ent i'eleplluttc No.Sigliatut•c LIC. NO.: L Bus. Tel. No.•1FzLl � Alt. 'Tel. No.: -s 1161 h ve the liability insurance coverage normally t. I ain the (check or+c) ❑ owner ❑ owner's acent. rPjYRil11T FE- E: t 0. o otat No. of Recessed Irixturas No. ref Ccit.-a"usie. (Paddle) Fans Traaosformers KVA No. of I..lglcting Outlets No. of Idol I obs Generators INWA ` � P�Iao.a fit- i o. o mergeuey tg ! oag No. of Lighting Fixtures Stslrroottlaa I' rnd. ^� Ji3ttery Units No. of Receptacle Outlets No, of OEI Burners EIS AI.A104S No. Of Zones ! o. of Vetectic an Initiating Deylces No. of Switclies No. of Gas Burners No, of Ranges otal No. of Air Coll 'Torts No. of Aleribig Devices of Waste Uispnsel ea=ml' er ._ons [�W o. 0 et - oNo. RDelectiato/Alertin Devices 5 ace/.F rea Reatin KW g Vocal ❑ rkne ti ❑ Other Cottnecttatt ers No. of Uisia»•asltcrs p� No. of Dryers Trleatlrtg Appliances ICV ecurity ysteltts. No. of Devices or E ,ulvalettt of�ValeK1V . t olosf oo iata Wim!g: Itcttcrs Signs Bats No. ofDevices or Equivalent No. Hydromassage Bathtubs No. of 111olors 'Total I-IV I'elecommuoa entions Wiring: No, of Devices ori~ uivatent OTi-lER- Attach addilional detail if desired, or as required by the luspector of [Mees. INSURANCE COV EItAAGE.: Unless waived by the owner, no permit fur the performance of electrical work may issue unless the licensee provides proof of liability in ance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cover, is in force, and lass exhibiled. proof of sante to the permit issuing Offic�'- CHECK ONE: INSURANCE 13�ND 0 OTHER [] (Specify:) Y (Expiration Date) E=stimated Value of Electrical Work: �� (When required by ntuuicipal policy.) work to Start; D 111spections to be requested in accordance with 1VIEC Rule 10, and upon completion, / cc�rtijj, ululcr the' l,aitr ll{crralttrs ujl,,�,jlr , rl,ur etre til »,a,inrr n» this application is trite and completa. i� I1t,11 NAnII:: f .%%%_... �--P °�r� r- 4 LIC. NO.: Signature (lf applicable, seer ..scarp[" Err the license nrrluber tin 1 Address: 1 l �a _ �� �! %� r%th 0WNERt'S I 1 :1NCk 1 41 VE It: am a%varc° that the Li doe required by law. Dy my signature below, I hereby waive this requircmcn Owneri'A ;ent i'eleplluttc No.Sigliatut•c LIC. NO.: L Bus. Tel. No.•1FzLl � Alt. 'Tel. No.: -s 1161 h ve the liability insurance coverage normally t. I ain the (check or+c) ❑ owner ❑ owner's acent. rPjYRil11T FE- E: Date ..... ....... 1,3 ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING jL- / -,- 1-91 This certifies that .......................................................... has permission to perfonn ........ ....... /?"tp wiring in the building of ......... r RJAI .................................................................. -P ... !P.C—.40 ... �� 77736.0;4 .................... 1P..7 N er, Mass. 'tee::-,�Lic. No. Y ... ....... E Ec P. Check # 11480 � Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. qb Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code (IvMC), 527 CMR 12.00 (PLEA SEPRINTWINKORTYPEALLINFORMATION) Date: City or Town oh 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) 0 Cry /� Owner or Tenant g–jf, Telephone No. �' -lo -�bZS WORK Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Overhead ❑ Yes ❑ No 9 (Check Appropriate Box) Utility Authorization No. - Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Overhead ❑ Undgrd ❑ No. of Meters Undgrd ❑ No. of Meters Location and Nature of Proposed Electrical Work: / lJl'V(J�Ft►'l� vwu Ommnlatznn nfthp fnllowing table may be waived by the Inspector of Wires. o. of Recessed Luminaires o. of Luminaire Outlets o. of Luminaires o. of Receptacle Outlets o. of Switches o. of Ranges o. of Waste Disposers No. of Dishwashers of Dryers r atei KW Heaters Hydromassage Bathtubs No. of Cell: Susp. (Paddle) Fans N0. OI J. Vial Transformers KVA No. of Hot Tubs Generators KVA AboveIn- Swimming Pool rnd. ❑ grnd. ❑ o. o mergency ig ting Battery Units No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection and No. of Gas Burners Initiating Devices No. of Air Cond. Total Tons No. of Alerting Devices APafPmmn I Nnmher I Tons I KW No. ofSelf-Contained Space/Area Heating KW Heating Appliances KW No. of No. of Signs Ballasts No. of Motors Total HP Municipai er al ❑ Connection ElOth urity Systems:* No of Devices or Equivalent :a Wiring: No of Devices or Equivalent ecommunications Wiring: No. of Devices or Equivalent OTHER: ' Attach additional detail zf desired, or as required by the Inspector of Wires Estimated Value of Electrical Work: —2' (When required by municipal policy.) Work to Start: Inspections to Ke 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 0 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of per'u , that the information on this application is true and complete. FIRM NAME:. �? l ��i LIC. NO.: ! I Licensee: Ste„_ t * I S, Signature LTC. NO.: (If applicable, enter "exempt" in the lie-77-=(01nse nu ber line.) Bus. Tel. No.-61 Address: 10 �21iffil MO Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security w rk requires Department oyPublic 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 si nature be ow, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent ���,�� 1 t '��j/ %'* 11 0 PERMIT FEE. $ fS Signature Telepho yio. ❑ 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 1.73 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 effector 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 IN Re- Inspection Required ($.) ❑ ' Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed ❑' Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: e k - Inspectors Signature:f r,� U .'. - Uwp� z Date \. - rZ,1� LDEBWEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com 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: Phone #: Are you an employer? Check the appropriate box: L ❑ 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 are 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.] i 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.❑ Roof repairs 13.❑ 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 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. am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site zformation. isurance Company Name: oliq or Self -ins. Lic. #: )b Site Address: Expiration Date: City/State/Zip: .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 ne 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 Cup to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of tvestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury 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): L 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 stale 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 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 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 Fax # 617-727-7749 evised5-26-OS Division of Professional Licensure: License Search The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure > Check A Professional License By the Division of Professional Licensure LICENSEE Name: STEVEN N. PITHIS Business: APOLLO ELECTRIC COMPANY NORTH READING, MA NEW SEARCH **This Licensee has additional Licenses, click here to view them.** U 9 This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Tuesday, April 02, 2013 at 8:32:53 AM. © 2007-2011 Commonwealth of Massachusetts Page 1 of 1 Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATED INFO Disclaimer Regarding Website License Searches Enforcement Process Glossary Glossary of License Status Codes More Site Policies Contact Us http://license.reg. state.ma.us/publiclpubLicenseQ. asp?board_code=EL&type class=_A&Iic... 4/2/2013 Licensing Board: ELECTRICIANS MASTER ELECTRICIAN License Type: TYPE CLASS: A License Number: 11489 Status: CURRENT Expiration Date: 7/31/2013 Issue Date: 7/28/1986 Exam Date: 6/7/1986 iI ! School: 9 This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Tuesday, April 02, 2013 at 8:32:53 AM. © 2007-2011 Commonwealth of Massachusetts Page 1 of 1 Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATED INFO Disclaimer Regarding Website License Searches Enforcement Process Glossary Glossary of License Status Codes More Site Policies Contact Us http://license.reg. state.ma.us/publiclpubLicenseQ. asp?board_code=EL&type class=_A&Iic... 4/2/2013 Q � Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [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 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATIOA9 Date: 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) ® L9 6q( -t AA -kA 1 Owner or Tenant �l Z��- Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No EMIR, (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 Location and Nature of Proposed EIectrical Work: Vve4V(/� �J hI�1F1✓l. �'►^^�> > Completion of thefollowing table may be waived by the Inspector of Wires of Recessed Luminaires of Luminaire Outlets of Luminaires of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers No. Hydromassage Bathtubs INo. of Ceil: Susp. (Paddle) Fans lTransformers KVA I No, of Hot Tubs Swimming Pool Above ElJ.n- ❑ grnd. grnd. No. of Oil Burners No. of Gas Burners No. of Air Cond. Total Tons Heat Pump Totals: Number. Tons. KW......... Space/Area Heating KW Heating Appliances KW No. of Signs No. of Ballasts No. of Motors Total HP Generators KVA No. of Emerg mey Lighting Battery Units FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Alerting Devices No. of Self -Contained Detection/Alerting Devices Local Connection❑Municipal ❑ Other Security Systems:* No of Devices or Equivalent Data Wiring: No of Devices or Equivalent -Telecommunications Wiring: Nn_ of Devices or Eauivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: —2 (When required by municipal policy.) Work to Start: Inspections to e 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: 1NSURA_NCE ❑ BOND ❑ OTHER ❑ (Specify:) X certify, under the pains and penalties ofp rturv, that the information on this application is true and complete. FIRM NAME:. ­�z l "-�,-C S, LIC. NO.: A Licensee:j,ti�l� > Signature LTC. NO.: y (If applicable, enter "exempt" in the license nu ber Zine.) Bus. Tel. No.• - o Address: U X21- f o Ajx&&o(M t O Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security wdrk requires Department ofVPublic Safety "S" icense. Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally-, required bylaw. By my si �7ow,waive this%re�quireme�n/t. qI am the (chCeck one)[] owner ❑owner's agent. Owner/Agent % Telepholrc o.t� �0 lU 1l 0> PERMIT FEE: $ ��, Signature � 7W l -�n 9-33_< 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 ® Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass R Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F?1 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Commeents: . ;3- �3 f Inspectors Signature: ��,1 ep LI6Vl�12 - ua, pc=72 Date �{1p-• WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com