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HomeMy WebLinkAboutMiscellaneous - 103 FULLER ROAD 4/30/20189457 Date.....?.... y:.. �.U..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that 0 v��K- .................................. ........ has permission to perform /l� ...h?/...L/liUSJ �ifti S .......................................... wiring in the building of ............ G So�v.............................................. at ......�.�..3... wcL....2_.... .................... ... North Andover, Mass. ...................Fee.,�—P........ Lic. No.ls3�q4 .............. . ...... LINSPECTO$� Check # Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 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 PRINTININK OR TYPE ALL INFORMATION Date: j, - 4/ City or Town of: NORTH ANDOVER TO the By this application the undersigned gives notice of his or her intention to perform the ele electrical workpector of idescribed belo Location (Street & Number "�'' Owner or Tenant Owner's Address a VX Telephone No. Is this permit in conjunction with a building permit? Yes 195 No (Check Appropriate Box) Purpose of Building_ / /` I pr .moist / ' Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Una d `�' ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: Completion of the followin table maybe waived by the Inspector of Wires. No. of Recessed Luminaires No, of CeiL-Susp. (Paddle) Fans o• of Total Transformers KVAA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No, of Waste Disposers No. of Dishwashers No. of Dryers Heaters KW No. Hydromassage Bathtubs Swimming Pool ,Xuuve ❑ ------------ d No. of Oil Burners No. of Gas Burners No. of Air -Con—CLT� Area Heating KW .g Appliances KW No. of :ns Ballasts . 1140. of .Lmergency ig ig Battery Units FIRE ALARMSr1;. of 2vnen No..of Detection and I—niffiating Devices No. of Alerting Devices o. of Self -Contained Detection/Alerting Devices Local ❑ Municipal Connection ❑ Other Security Systems:* No. of Devices or Equivalent Data wiring: No. of Deviem nr' ...nvv.1—+ No. of Motors Total gp Telecomm No. of Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: Work to Start b40 (When required by municipal policy.) 9 j4 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 R BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalises of perjury, that the inforneadon on this application is true and complete. FIRM NAME: 3? T -N el -&C ' Z," / Licensee: LIC. NO.: Sigaatur _ (If applicable �n ,e "e pt " in the ' ense number ,) LIC. NO.: Address: y o ©1 Z Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of PublicSafety "S" icense: Alt. Tel No.. 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: $ 712e Commonwe¢lth of 1Vfassachusetts Department of Industrial Accidents Office of ,fin Veda ations ..600 Washinpon Street Boston, AIA 62111 www.massgov/din Workers' Compensation Insurance �plicant Information A.Tdavitr: Builders/Contractors/Electricians/Plumbers . . icase j`I'lIIt LeQil)IV Name (Business/Or.-mizatim/Individual): Address: City/Sxate/Zip:�//" - phone #: Are you an employer? Check the appropriate box: — 1. ❑ I am a employer with 4. ❑ I am a F7R f project (required): "neral contractor and I 2.� employees (full and/or part-time) * have hired the sub -contractors Neu, construction I am a sole proprietor or partner_ listed on the attached sheet $ emodeling ship and have no employees Theseb-contraetors have workino for me in an capacity. workers comp. ins Demolition a Y � P �'' � P insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its 9. ❑ Building addition required.] officers have exercised their 10•3PElectrical repairs or additions 3. ❑ I am a homeowner doing all work right of ex emption per MGL 1 L Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t [No workers' employees. 12.[] Roof repairs ` comp. insurance required.] 1 13•❑ Other a^glic'-t that Checks bo:: l must a?so uu out Zlozneowners -ho submit this affidavit indicating dol , .. A'art;._s' com^--s-_n the a._ g aL work and r -- — r _ '`Contractors that check this box must attached an additional sheet showing hire outside conaactora 4" a submit a new affidavit indicating such. o the name of the sub -contractors and their workers' nn_ .,^.:_ nun an employer mat tS pTOVidin--- r- ..auiwauvn. e workers' compensation surance for my employees. Below is the oli information. inp cy and job site Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: Attach a copy of the workers' City/State/Zip: compensation policy declaration page (sho R Failure to secure coverage as required under Section 25A ofMGL c. 152 can tPoIicyo the oS tubertiOn o f and expiration date). fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties criminal Penalties of a Of up to $250.00 a day against the violator. Be advised that a co P sin the form of a STOP WORK ORDER and a fine Investigations of the DIA for insurance coverage verification PY of statement maybe forwarded to the office of y �s�y Ler the pains d pe 'es ojPerjurJi that the information provided above is true and correct Siaturc: r _. Date.:._ Phone #: r 2j O P -- P 3 Official use only. Do not write in this area, to be completed bJ' cixj, or town ofjzcuil City or Town: Permit/License # issuin D Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. EiectricaI Inspector 5. Plumbing 6. Other a Inspector Contact Person: Phone #: Date. °'. •° :'�o TOWN OF NORTH ANDOVER a PERMIT FOR PLUMBING •p. SSA�MUS� This certifies that . �..> . f.,�,�f1..�.....�...� ............... has permission to perform .... ................ plumbing in the buildings of ..A.-!. (..S.r t...................... at 4 rl- < <.�. � .. � t �................... . North Andover, Mass. Fee�T '. Lic. No.. .. .... ._........ . PLUMBING IN PECTOR Check # 1 S 0657 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Owner New ❑ Renovation ❑ Replacement FYXTITRFc Date G —iy—i� Permit # Amount Plans Submitted Yes ❑ No (Print or type) P W Check one: Certificate Installing Company Name ll 0 Corp. Address d VF er. Business Telephone /Co. Name of Licensed Plumber: Insurance Coverage: Indicate the 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 three insurance I hereby certify that all of the details and inf best of my knowledge and that all plumbing compliance with all pertinent provisions of the By: C Title City/Town APPROVED (OFFICE USE ONLY — ::ion er I hubmi (rgm and mstallati nerf na , I Type of Plumbir4 LicensC z6Z6 / rcense um er Master ❑ cation are true and accurate to the d for this application will be in .er 142 of the General Laws. Journeyman ❑ 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 __1 i a�.uoc. 1 1 Name (Business/Organization/Individual): 6 G Address:_ t� `� h-� City/State/Zip: Phone #:_9 an employer? Check the appropriate box: XAreon am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole have hired the sub -contractors listed proprietor or partner- 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.] 3. ❑ .I am a homeowner doing all work officers have exercised their 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 -- .11 ,.., — cuc +C"ROn nmow sn0'M^ . th— p"' policy mform— ton. b .....0 wod:,^ --p----tion S. t 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 information. n insurance for my employees Below, is the policy and job site �' Insurance Company Policy # or Self -ins. Lic. #. / Expiration Date: Job Site Address: ( 00t e� f s �� 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 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 $25 a day against the violator. Be /advised that a copy of this statement may be forwarded to the Office of Investi tions of the IA for insurance cover�fuP k,P.;fi�at;n„ I do her certify 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): 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-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 permait 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 of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE Fax # 617-72.7-7749 Revised 5-26-05 vvwu .mass..govfdia APPLICANT. LOCATION: CITY, STATE: A 1994 (c) Boston Survey So. PREPARED: 0 SCALE: 1 inch = 6( CERTIFIED TO- 11 MORTGAGE INSPECTION PLAN BOS'T'ON SURVEY, INC. 98-03953 P.O. Box 220 Charlestown, MA 02129 (617)212-1313 MAIN (617)242-1616 FAX NELSON 103 FULLER ROAD NORTH ANDOVER, MA DEED/CERT: 97-57 PLAN REF: 36903C _ Location AM No. :� --:e.'z Date �aRTM TOWN OF NORTH ANDOVER AL 9 Certificate of Occupancy $ ,", Building/Frame Permit Fee $-U �'�b'••°''<�' sswCHust Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ r✓ TOTAL $r It -r Building Inspector Div. Public Works -k � ❑ F, � U �' C Z > W. O - p Z ? ❑ C. -- w o C 0. 0 0 0 C U U U i j O tw-U U C7 p Z Z Z M. ❑❑ .: U ZZ Z' Z ~ Z O O O O U U. U w z w o o- o. O w. S. c o a o U O w "" Z Z Z F w -] � G O w � Z � W w V O � ❑ ❑ O O O < '4 L L L W N < ❑ ❑. ❑ ❑ r � N G Z ❑ vl to ..3 _7 p � N G � � � � h^moi Or z � - o O Z I U C w Z a V ❑ U `\ F � a �, 2F ..a U w d < .� O M Z c y rn p � cn F z w c„ F ? Z C O O O c cn O VV < L U �-7• ^ L h O C O ...1 Cry F- w W_ <W U < F C- r - 0 r - C - . N In s w w W z z z p ~ .. .. U Oz La w°J ` i a U W L z v z Q e oM� - J � p I � _ W L � Z w c,Wi cil > V � J � W W F W rn F- � U J ❑ C C �t z lv, -k � ❑ F, � U �' C Z > W. O - p Z ? ❑ C. -- w o C 0. 0 0 0 C U U U i j O tw-U U C7 p Z Z Z M. ❑❑ .: U ZZ Z' Z ~ Z O O O O U U. U w z w o o- o. O w. S. c o a o U O w "" Z Z Z F w -] � G O w � Z � W w V O � ❑ ❑ O O O < '4 L L L W N < ❑ ❑. ❑ ❑ r � N G Z ❑ vl to ..3 _7 p � N G � � � � h^moi Or z � - o O Z I U C w Z a V ❑ U `\ F � a �, 2F ..a U w d < .� O M Z c y rn p � cn F z w c„ F ? Z C O O O c cn O VV < L U �-7• ^ L h O C O ...1 Cry F- w W_ <W U < F C- r - 0 r - C - . N In s w w W z z z p ~ .. .. U Oz La w°J ` i a U W L z v z Q e C oM� - J � p I � _ W L � Z L c,Wi cil > V � J � W W F W rn F- � U J ❑ C C �t C W � p � _ W L � Z L c,Wi cil > i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: J,gse rJ Location: / O 3 E�) . City/'hril L6\/C�L Phone aam a homeowner performing all work myself. =I am a sole proprietor and have no one working in any capacity F-T.,-Tfam an employer providing workers' compensation for my employees working on this job. Company name: e/4SO N �f/.eE/��-7— 0VP'N7-RY J/eo fAddress j City: 66 K Phone #: 9,760 61d - 35�� Insurance Co. U17%/"62ye/ 11A-) Policy # W C �- Company name: Address City: Phone #• Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do herby certify unnd penaltie erjury that the informaBoe and correct. Signature' Date 10-1;2-,93 Print nameSa�(/2E,q-, y� Phone n-39 Official use only do not write in this area to be completed'by city or town official' Building Dept ❑Check if immediate response is required Building Dept p Lincensing Board M Selectman's Office Contact person: Phone #. Health Department Other FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from - Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS APPLICANT 4SO^-) (J� % PHONE LOCATION: Assessors Map Number 0(,O5— PARCIE:1. O d O co V SUBDIVISION LOT (S) STREET �� ( 2D ST. NUMBER /0 3 * ******** ****** tr0 F F1C lAL USE ONLY*********************-*... RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED 1� DATE REJECTED • -8 .. � - 13 -1\ oe �v J O TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING ! JSPECTO Revised ati°' jm DATE -u � . � - - ,�-.� t 1 '. r ,t �_G.� BUILDING DEPARTMENT DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 S 54, a condition of Building Permit Number Is that the debris resulting form this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150A The debris will be disposed of in: Location of Facility �ignature of Permit Applicant Date. NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector has permission to swi.. r.......... ..�.)............ ............................ .. 1 1111 .P..........uildings on .... '! rft ................ ...................................................................... to be occupied as ..a� a �"..5,�""y' P s ......... �.conform to the ....K� N provided that the person accepting this permit shall m eve respect this office, and to the provisions of the Codes and By -Laws relangto the inspection, Alteration aof the nd�Construct Construction of Buildings in the Town of North Andover. VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS ffi oZ UNLESS CONS TRUCTION ST S rJoe forl e ........ .... . . ................... ........................... BUILDING INSPECTOR Occupancy Permit Required to Occupy Building Display in a Conspicuous Place on the Premises — Do Not Remove No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. 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