HomeMy WebLinkAboutMiscellaneous - 100 ANDOVER BY-PASS 4/30/2018 (9)iE
0
O
I
Commonwealth Of Massachusetts
Official Use Only
Department of Fire Services Permit No.�
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07
Qeave 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 flVfl%K OR TYPE ALL INFORM,4TIOA9 Date:
City or Town of: NORTH ANDOVER
By this application the undersigned TO the Inspector of Wires:
gn gives notice o his or her intention to perform the electrical work described below.
Location (Street & Number) UQ
Owner or Tenant ,
Owner's Address Telephone No.
Is this permit in conjunction with a buildin ermit? Yes
Vj-C f No ❑ (Check Appropriate Boz)
Purpose of Building
' t iUtility Authorization No.
E�sting Service Amps / L,Volts Overhead
❑ Undgrd ❑ No. of Meters
New— S=rvtce Amps _ I Volts Overhead
Number of Feeders and Ampacity ❑ Undgrd ❑ No. of Meters
Location and Nature of Proposed Electrical Work.
��..� xenon o the jo[iowin table may be waived by the Inspector of Wires.
No. of Recessed Luminaires No. of Cei1-Sus No. of Total
p. (Paddle) Fans Transformers TO
No. of Luminaire Outlets No. of Hot Tubs
KVA
Generators KVA
No. of Luminaires Swimming pool Above� In_ d o, o mergency nng
U .
-- . No. of Receptacled• Batte nits
Outlets No. of Oil Burners ,
FIF_E ALARMe No. of Zones
No, of Switches No. of Gas Burners No. of Detection and
No. of Ranges Luuavn Devices .
g No. of Air Cond. T°2l
Tons No. of Alerting Devices
FNo.
Waste Disposers eat pOp Number Tons KW o. of Self -Contained
Totals: ""-" Deteetion/Aler(in Devices
Dishwashers Space/Aren Heating KW Local Municipal
,Dryers Heating A Connection Other
Appliances KW Security Systems;
IN o. of Water KW o. of No. of No. of Devices or Equivalent
Heaters Data Wiring: s Ballasts
No. H dromassa a Bathtubs No. of Devices OLE uivalent
y g No. of Motors Total Hp Telecommunications Wiring;
OTHER No. of Devices or E urvalent
I
(�+ Inspect
S
Attach additional detail if desired, oras required by the Inspector of Wires.
Estimated Value of Electrical Work: JOC1
Work to Start // / (When required by municipal policy.)
ions to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE_0_0'RAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify, under the sins andpenalties ofperjury that the information on this application is true and complete
FIRM N
LIC. NO.: 0, 20
Licensee: t° Signature
(If applicable enter "exen t' in the Dense punkber line.) LIC. NO.: ,fern
Address: L r y.✓ w.- ti Ol V Ci N��j 3G�"1 Bus. Tel. No
*Per M.G.L c. 147, s. 57-61, security work requires Department of Pub is Safety "S" License: Alt L cl No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the IiabiIity insurance coverage no
rmally
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. $
946U
Date .... 4...Z- '..��,....
f gOR7M
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
,SSACNUSE�
�T
This certifies that IIrL
has permission to perform ......
...................................................
wiring in the building of 14 E 5 /7 /
......................... D.......................................
at ... d0.... A.O4W .. ��!. AA .................. h Andov ,Mass.
Fee ... 1.2-s �'.. Lic. No.D63tyi
``f��G .......
ELECTRICAL INSP>tCTOR
Check # 1794 L
The Commonwer¢lth of lMassachuseas
opDepartment of Iradustrial _9ccidents
Office offnvesticrations
600 Rrashin;ion Street
Boston, M4 02171
x'n'w-masS-gov/di¢
Workers' Compensation Insurance
�plieant formation �da�rit: guilders/Contractors/Electricians/Plumbers
in
Name(Business/Organization/Indivi dual):
Address:
W -o / 12f^
City/Sate/Zip:'ti,Qv��j`a,&
%Utl/�
(Z?Of 2_ Phone #:__I Z'7 o�& 0
Are you as employer? Check the appropriate boa:
I N�l am a employer with o2 4. ❑ I am a
employee fill and/or part-time).* have �d ral the contractor and I
Y A P ) the sub -c
?. ❑ I am a sole ontractors
Proprietor or partner- listed on the attached sheet x
ship and have no employees 1 -nese sul>_ contractors have
working for me in any capacity. workers, comp- insurance.
comp, [No workers' co, insurance 5. El We are a co
required.]
❑ I am a homeowner doing all work
Myself . [No workers' comp.
insurance required,] t
i.F on and its
ofncets have exercised their
richt of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required ]
=Iic a± that h �k trsx -] a:eSi wsc, nu out the sece^^ �:o
Homeowners who submi±this afndavit indi zting th R, ere d - n o� {" n ort as' comi
�g a. wore and =
1Contractors that cheek tkas box must attached an additional sheet show' a � hire otziside conec ' " ° i su�ic a new aizidavit indi=ting such.
the name of the sub -con= --t— and their workers'
r_
Type of project (required):
6• ❑ Nevv construction
7. ❑Remodeling
8. ❑ .Demolition
9• ❑ Building addition
10.❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12•7 Roof repairs
13. ❑ Other
cwnpkryer curt is providing workers' compensadon insurance for m em
informadon. Y employees.
Insurance Company Name:STC 7
Policy # or Self -ins. Lic. #;
Below, is the policy and job site
Expiration Date:
Job Site Address: U k Sf
Attach a co City/Stateizip:lvc,,-T,'
copy of the workers' compensation secure
declaration page (showinb the policy number and expiration date).
fine up to $1,500.00 and/or one-year impriso
Failure to sure coverage as required under Section 25 A of MGL C. 152 can lead to the imposition of criminal penalties of a
nment, as well as civil
Of up to 5250.00 a da ag ' Penalties in the form of a STOP WORK ORDER and a i3ne
3 ainsi the violator. Be advised that a copy of statement may be forwarded to the, Office of
Investigations of the DIA for insurance coverage verificarion.
I do hereby cerdfy under the pains and penaWes of perjury th zt the formahor provided above is true ¢ correct-
official
orrect
official use only. Do not write in this area, to be completed bJ' citj, or town official
City or Town: Permit/License #
Issuing Authority (circie one):
1• Board of Health 2. Building Department 3. City/Town Clerk
6. Other 4. Eiecrzical Inspector 5. Plumbic; iasnector
Contact Person:
Phone :,5,:
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
p Date ' -y
/
Building Location ! 6c) ll 4)wners Name R + C ��*iy'�a 't5 Permit #-27Z
nn Amount
5 V I �-t, 4 D Type of Occupancy
New a— Renovation
Replacement 0
nrvmrro V e
Plans Submitted Yes[]
No
:..
(Print or type) i1 Check one: Certificate
Installing Company Name --Q an 11 Corp.
El Partner.
n Firm/Co.
Name of Licensed Plumber:
Insurance Coverage- Indicate the type of insurance coverage by checking the appropriate box: ❑
Liability insurance policy ®/ Other type of indemnity ❑ Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
ignature 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 w�Mistaffiitions performed under Permit Issued for this application will be in
compliance with all pertinent provisions oftheto ing Code and Chapter 142 ofthe General Laws.
By: Signature -61U—cenSed Plumber
Type of Plumbing License
Title '71 1 c& 1-1
City/Town 17cense Rumoer Master r-1 Journeyman
APPROVED (OFFICE USE ONLY
NONNI
,.. ......Now
..............NMI
......................1
No
MM
..., ,....�■...........=1MW1M
.MOM
No
• • MM
MW
W......M1MEM
,.,.. .......................No
ME
MMMO1MM
0
mom
mom
(Print or type) i1 Check one: Certificate
Installing Company Name --Q an 11 Corp.
El Partner.
n Firm/Co.
Name of Licensed Plumber:
Insurance Coverage- Indicate the type of insurance coverage by checking the appropriate box: ❑
Liability insurance policy ®/ Other type of indemnity ❑ Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
ignature 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 w�Mistaffiitions performed under Permit Issued for this application will be in
compliance with all pertinent provisions oftheto ing Code and Chapter 142 ofthe General Laws.
By: Signature -61U—cenSed Plumber
Type of Plumbing License
Title '71 1 c& 1-1
City/Town 17cense Rumoer Master r-1 Journeyman
APPROVED (OFFICE USE ONLY
Date 41 �-- - / .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ......................
has permission to perform .... ........................
plumbing in the buildings of .. llir sr�!
at !1 <<. ,North Andover, Mass.
t
Fee . � ..... Lie. No.. �. `.1� . .......... .... .. !'..... .
PLUMBING INSPECOR
Check ff 1 4 Cl
8340
.» The Comnzonweizlth of llfassachusetis
kipDepartment. of rndustikl Accidents
Office of _rovesfib ations
600 Washington street
BOstOn, ALL 02111
www.rnassgov/din
Workers' Compensation Ttnsuranc
Anlieant Information e Affidavit: guilders/Contractors/Electricians/Plumbers
PIease Print Lea-ib3,.
Name (Business/Organizatio&ffidividual):
Address:
City/State/Zip:
Phone #:
'Axe you an employer? Check the appropriate
box:
. ❑ I am a employer with
4. ❑ I am a general contractor
employees (full and/orpart-time).*
I am a
and I
have hired the sulrcontractors
sole proprietor or partner-
listed on t:hc attached sheet I
ship and have no employees
These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
workers' comp- insurance.
5. ❑ We are a corporation and its
• - required.]
3. F7 am a homeowner loin¢
- ofricers have exercised their
all work
Myself [No workers' comp.
right of exemption per MGL
C. 152, § 1(4), and we have
insurance required.] t
no
employees. [No workers'
POMP- insurance required.]
w. A
= nY cW.t that chez..." s box%#' "..2'_-4t also El L�f fhc ae crow =0 ja•, ;
Horueown= w' s — R0n"—mss' co
Type of project (required):
6- ❑ Neur construction
7. ❑ Remodeling
8. ❑ I)emolition
9. ❑ Building addition
10 ❑ Electrical repairs or additions
.11.0 Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
no sunm,tttus afiidavn indicating they am dog ��t „ r-- __Y,;.:;.; �
+Contractors +fat check tt ? o.*. n • . _ ik and ileo hirenutsi& eoaaaeto . slit st wit a new affidavit indicating such.
achEd additional sheet showin; the same of the sub-conuactors and their workers' comp. poiirinformatiaa
Iain an employer that isproviding workers' comp
information, ensation iaszirance for my employees. Below is the policy andjob site
Insurance Company Name:
Policy # or Self -ins. Lir. #..
Expiration Date:
Job Site Address:
City/State/Zip:
Attach a copy -of the workers' compensation policy declaration page (sliawing the Policy number and expiration date).
line up to $1,500.00 and/or one
failure to secure coverage o required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a one
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby certify under the pains and penalties of perjury th¢t thc information provided above*is true and correct.
Official use only. Do not write in this area, to be completed b3, cj, or town ofJiciaL
Cita, or Town:
,sum' .1 Authority (circle one):
L Board of Health 2. Building Department 3
6. Other
Contact Persurr:
P ermitucense
Crty/Tow. Clerk 4. EIectrical Inspector 5. Plumbing Inspector
Phone'*:
FJ ,
Information an- d Instructions v
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 hue,
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 t3ae legal. representatives of a deceased emplover, or the
receiver or trustee of an individual, partnership, association ox- other legal entity, employing employees. However the
owner of a dwelling house having not more than three agar nz ents and who resides therein, or the occupant of the
dwelling house of another who employs persons to do mainte;:3ance, 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 bean e:mployer."
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 co vnpliance 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 ua--til 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 numbers) 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' comp =sation incnrmze. 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 rutuuvd t0 the vuy or toh n_ that %IIs c4ruiica.LLM fur the perriaitQr licm-e $ fh
btmg requestzd, not e. 'epartment Of
Industrial Accidents. Should you have any oues6one regardim- g `fie lam' or i you are -'in:: �d 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 legrblg7. 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 tocontact 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 giyeIl 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 stampe=d 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 oul 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 iicemse or permit to bum leaves etc.) said person is NOT required to complete this affidavit
The Office of Investigations would like to than you in advance f6r your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department°s address, telephono.and.fax.number._._
Tle Commonwealfiz of M ssac usetts
Depar emt of Fndustriaj Accidents
Office of lmlesfi°afians
600 Wasbit 2Zan Street
BO -Ston, MA 02111
Tel. #• 617-727-4900 = 406 or 1-9 -/
Revised 5-26-05
Fay: # 6.17-7727-7749
wRra,.masm-gov/dia