The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 105 HILLSIDE ROAD 4/30/2018 (3)5 , 40RT" 0 0 S C us. This certifies that Date.............`. ... ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING �...:..d,....."le', ... ........ .......................... G/ has permission t6perform—.--'L--'7!-�::�:%... ...................................................... wiring in the building of ....... ....... at ................... .................. ............ North Andover, Mass. Feed:-..:. ..... ..... Lic. ................. ....... ...................... ELECTRICAL INspEcToIV, Check # 0*. Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. yk� Occupancy and Fee Checked L'Rs ,ev. 1/07] nPavP h�a„U� —�— APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /�jg,�G,,�j gr 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) /pg Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? yes C Purpose of Building TS;A4 �o �/l7i�U /lam Telephone N;r-7'y No ❑ (Check Appropriate Box) Utility Authorization No. Existing Service ilk Amps /ZQ / ZVV Volts Overhead [2'- Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: /ono' U& od,�/l in zA` No. of Meters No. of Meters attach additional detail if desired, oras required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 cov office. ge is in force, and has exhibited proof of same to the permit issuing oce. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: Signatu LIC. NO.: (If applicable, enter ` exemp " in the lie a umber li .) Bus. Tel. No.: / Address: *Per M.G.L c. 47, s. 57-61, sec city work requires Department of Public Safety "S" License: Alt L cl. 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: $ • -« ��« wf, aaucc mayoe waivea oy the inspector of wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires <2 Swimming Pool Above ❑ In- ❑ o. o mergency Lighting rnd. rnd. Batte Units No. of Receptacle Outlets / No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges Air Cond. Tons No. of Alerting Devices No. of Waste Disposers t Pump Number Tons KW No. of Self -Contained tNo.of Totals:.........................Detection/Alertin Devices No. of Dishwashers ce/Area Heatin KW g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Water No. of Devices or Equivalent Heaters KW No. of No. of —Data Signs Ballasts of DWirinevices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications icing: No. of Devices or Equivalent OTHER: attach additional detail if desired, oras required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 cov office. ge is in force, and has exhibited proof of same to the permit issuing oce. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: Signatu LIC. NO.: (If applicable, enter ` exemp " in the lie a umber li .) Bus. Tel. No.: / Address: *Per M.G.L c. 47, s. 57-61, sec city work requires Department of Public Safety "S" License: Alt L cl. 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: $ k I/ } f % J lk r; i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 { l www.nzass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aontiicant Information Please Print Legibly Naixie (Business/Organization/individual}; Address: City/.State/Zip: O/kJ/ Phone #: . Are you an employer? Check the appropriate box: I ❑ 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. 3 ship and have no employees These sub -contractors have working for mein 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. 1.52, § 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. Q Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.[] Roof repairs 13J7 Other -nny appucant tnat aneeks bort # l must also fill out the section below showing their workers' compensation policy information. �. t Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. r ;Contractors that check this box must attached an additional sheet showing the name ofthe sub -contractors and their workers' comp. policy infotmadon. lam an employer that is providing.workers' compensation insurance for my employees: Below is. the policy and job site informaiom Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: 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 WORT{ 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 herebyrte u der th ains an Haloes of er' that the information provided above is true and correct Si tore: Date: t 8' Phon 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 Cierk 4. -Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: P� 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 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 -contractors) 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 cavy 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 ifyou .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 tine. 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, needonly 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 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 42111 Tel. # 617-7274900 ext 406 or 1-8.77-MASSAFE Fax # 617-727-774 Revised 5-26-05 www.mass.govIdle Dated �'< •� :�� LPEIMIT OF NORTH ANDOVER .- FOR PLUMBING SSACMUS� This certifies that .. ! }•.... ....:..... has permission to perform f plumbing in the buildings of ._ .r-�^6' ............ at . /o s- ... ...... '� .. ,North 'Andover, Mass. zhI Fee Lic: NojG� .. f.... !?../..`.......... . _ iiii• _ PIUM.B1/NG/INSPECTOR y r% Check 6- 7681 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS /Date (� / Building Location �:Q/ Owners Name 0"-L l0/ 6"/?P;yCi'2 L Permit #� , Gf� Type of Occupancy Amount ,� p S' ,. �,/ y New 1:3 Renovation r Replacement ' Plans Submitted Yes No rl FTXTT Tit vc! (Print or type)-� Check one: Certificate Installing Company Name T� ( ,1a,�j -Corp. Address Partner. Business Telephone Firm/Co. A '^ Name of Licensed Plumber: �d 2 611 Insurance Coverage: Covera e• Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy M Other type of indemnity ❑ Bond Insurance Waiver. I, the undersigned, have been made aware that the licensee of this applicatio three insurance n does not have any one of the above Signature Owner ❑ Agent I hereby certify that all of the details and information I have submitted (or entered) in abov best of my knowledge and that all plumbing work and insta�� one�s erformedtunder� remit compliance with all pertinent provisions of the Massach�rts�StaitT,,;I�,.l r,�.f a By: Title City/Town APPROVED (OFFICE USE ONLY 5 Type of Plumbing License icense NumSer Master j 1 application are true and accurate to the Issued for this application will be in ►ptgr...142 of the General Laws. Journeyman ❑