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HomeMy WebLinkAboutMiscellaneous - 1060 OSGOOD STREET 4/30/2018 (19) I1� f BUILD"ING FIL • TOWN OF NORTH ANDOVER ` PERMIT FOR WIRING This certifies that . . . . • . dZ has permission to perform . . . . F .//. • . . • . . . . . . . . . . . . wiring in the building of . . . at . . . .� North Andover, Mass. Fee . . .�.-' ic. No. . . d�� . . . . .XTRICAL EL INSPECTO � Check# 7 7 10986 tl Commonwealth of Massachusetts Official Use Only Permit No. l �� Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),52 CMR V.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) 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) f�'teT Owner or Tenant y, ,- Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes JA— No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service/00 Amps ,�O/ :7-/k-Volts Overhead ❑ UndgrdNo.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: l / Completion of the following table maybe waived Ky the Inspector of Wires. /✓1�� 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 Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting 3 rnd. rnd. Battery 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 No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained p Totals: Detection/Ale ting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection Heating Appliances Security Systems:* No.of Dryers g pp Kms' No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications No.of Devices or Equivalent OTHER: ��,, ,,.,,.� Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of El ctrical Work: e%Z/ (When required by municipal policy.) Work to Start: a? Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE VE GE: 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,tinder the pains and penalties of perjury,that tthe i formation on this application is true and complete. FIRM NAME: . LIC.NO.: Licensee: z Signature LIC.NO.: (If applicable,enter "exem t"t he lice a number line.) Bus.Tel.No.: Address: /! V �` cs-t/ Alt.Tel.No.:,`-� r9 *Per M.G.L c. 147,s.57-61,secuKy work requires Department of Public 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 signature below,I hereby waive this requirement. I am the(check one)❑owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. e _ �y A�• y� rpt•�,�- _ y-�,� �yr�c�- •�•� 7� tic ... � ol _ �+�►�(�,�u.,.t]t�Tt+JrC-t�oi�•,�,•y.R1�1®��tn !►, _,.+u.`i��C�uLJt.R�.l'4JE®�J�.: � Ro . '�ssetX-�C 'ailefl•�C e-inspect ou requixeci($-'0.00)-C ns ectuzs'CID efts: - ( uspeeaxs' zgnatuxe�xtoitiaTs) Slate �.!��N'��T��CTIiDI�I•t 3'asser - 3+ailec�- rtensectoxte[txixecT($ D.00)- [ �ts�ectaz-s'c e�xts: (Xri Xiectozs� z afore Dmals) date 'asset--C � Ti'ailec�--C � ate-�s�eetso�xesXuzxe�($�0.fl0)�[ � as�ectoxs'comx¢e�xts: • Cjns-Vectors"Sign ature-).o UflHIS) Date ' sserT C Meci•-C �,�ectbxs'eoynme�fs: ( tspeetoxs',�zgttatuze��oniaTs) Data ��kTi�C3CXm�*7�OTS:' ' nspeetzoxtxeauklaa($50.00)•-[ BCtOx�'COL1T Ti].�T1.tS: . ��s,ectDx ' ignatuxe o xnitiaTs) - Pate ' I SPEC ED-'q-NdiT a 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 i Applicant Information Please Print Legibly Name (Business/Organization/Individual): Z ,,/1 Address: O/�`�l City/State/Zip:�!���� `'/ err- #: q2e �;Ie3 Are you an employer?Check a appropriate box: Type of project(required): 1 JI am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.� I am a sole proprietor or partner- listed on the attached sheet. E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers' comp.insurance. Y p tY• 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their l0ctrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]i employees. [No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i 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: Gyl�J7/i~i� CtY!(' p Poli,-y#or Self-ins.Lie.#: Expiration Date: Job Site Address: ©eo-e 45:9 �c�d City/State/Zip:, e 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 certify under t ains an penalties of perjury that the information provided above is tr a and Corr Ct. Si nature: Date: Phone 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 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 S 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 Revised 5-26-05 Fax# 617-727-7749 www.mass,gov/dia