Loading...
HomeMy WebLinkAboutMiscellaneous - 1060 OSGOOD STREET 4/30/2018 (16) J 61;tn4 BUILDING FILE 1 M I - 24 ? 1 The Commonwealth of Massachusetts s City\Town of North Andover Certificate of Inspection In accordance with 780 CMR,Chapter 1 (The Sixth Edition of the Massachusetts State Building Code) and Chapter 304 of the Acts of 2004 (an Act to further enhance fire and life safety),this temporary certificate of inspection is issued to the premise or structure or part thereof as herein identified. Identify Name of Establishment Certificate No. Issued to Falafel Cafe &Grill 1060-2014 Certificate Located at 1060 Osgood Street Expiration May 2015 Use Group Restaurant Occupancy Load Classification(s) Limit 20 This temporary certificate of inspection is hereby issued by the undersigned to certify that the premise,structure or portion thereof as herein specified has been inspected for general fire and life safety features. This certificate shall allow for the temporary use as herein described and in conformance with any and all conditions as identified below. It shall be framed behind clear glass and\or laminated and posted in a conspicuous place within the space as directed by the undersigned. Failure to post the certificate,failure to comply with conditions or, tampering with the contents of the certificate is strictly prohibited. Conditions of Temporary Use Name of Municipal Name of Municipal Gerald Brown,Bldg. Insp. Date of May 27, 2014 Fire Chief Building Commissioner Inspection Signature of Municipal Signature of Municipal Date of May 27, 201 Fire Chief Building Commissioner �j�. Issuance E Location + �, Date No. TOWN OF NORTH ANDOVER M 100 - = ` Certificate of Occupancy -- Building/Frame Permit Fee Foundation Permit Fee , t $ �- Other Permit Fee 15 ` � TOTAL $ C) Check# �aBullding Inspector f � ...-�' NORTH I Q�.11bE0 , ,, TOWN OF NORTH ANDOVER Y y yT 4 `°`"Ic"IWTED SIGN PERMIT �pSSgcH �y DATE: January 9, 2014 PERMIT: 019-14 THIS CERTIFIES THAT Kamal Zefta — Falafel Cafe and Grill has permission to erect signs on 1060 Osgood Street — Wall Sign, Mounment Siqn provide that the person accepting this Permit shall in every respect conform to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Sign Regulations in the Town of North Andover. Violation of the Zoning of Sign Regulations, Section #6, Voids this Permit. INTERNALLY ILLUMINATED SIGNS ARE PROHIBITED Inspector of Buildings Amount Paid:$30.00 Check 991 Receipt 27212 L _ 1 'r SIGN PERMIT APPLICATION ` 1600 Osgood Street-Building 20, Suite 2035 Map p� Parcel TOWN OF NORTH ANDOVER . DATE SUBMITTED % Site Owner �C� - � ApplicantW �S/�� � A/- 17EE/-'�Tele�� ���' Z.�0 Site Address !ova�v jSize of Proposed Sign_ -XkS-71 (2�:x (Zbl� r INTERNALLY ILLUMINATED SIGN PROIMITED How attached: a) Against the wall b) Roof Illumination: a)Not illuminated c) Ground b)Externally illuminated d) Other Materials: NU(„ �� M.�►J Jyw�,-�,�T Proposed Colors: Background _ 7 �' ' Lettering�,,�,EA4.�--�'ST _ �''��� 1 — Z _11 Border Required Attachments: Photographs of building Note: No permanent/temporary sign shall be erected, or enlarged until an ✓Iaterial sample application on the appropriate form furnished by the Sign Office has been Color sample filed with the Sign Officer containing such information including Site or Plot Plan (Required for all free-standing signs) photographs,plans and scale drawings, as he may require, and a permit +� ( q g � ) q Drawings of proposed sign for such erection, alteration, or enlargement has been issued by him. Other, specify Such permit shall be issued only of the Sign Officer determines that the sign complies or will comply with all applicable provisions of the By- Law. Will sign overhang any public road or walkway Yes.( ) No If Yes,Name of Agency who will provide liability insurance: AN INCOMPLETE APPLICATION WILL NOT BE ACCEPTED DATE FILED: SIGNAT PLICANT i r caLaZano Hand Paint or Vinyl Decal � MAGNETIC BOATS TRUCK LETTERING & SIGNS PLAOD WINDOWS STIC SANDBLASTED 12 Riverdale St. BANNERS LOGO DESIGN Methuen, MA 01844 RACE CARS Phone / Fax 978/683-9250 978/683-2723 Custom * Pinstripe & Airbrush 25 Years of Craftsmanship FALAFELr� CAFE & GRILL FALAFEL CAFE. & GRILL �'" FAA L A F E L CAFE & GRILLD. Date.... f.............. TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING �s8wcHuss This certifies that.... '...........�.�:...... ,.::��.h�:l.!�:...... ............................................ has permission to perform......�v.1.ZA .vr,±n ......p,.W `� ,1 r ..}. . ....t..........�?..... .` plumbing in three buildings of..-' '! i. :..... .�............................................ at.....Lt. l .........v..�'....`..�........k........ ............ North Andover, Mass. S . Fee�v1............ .3...... ..... ..... ............................................. . Lic. No. .. . PLUMBING INSPECTOR Check# y i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - CITY Al MA DATE !�_zv�y ( PERMIT# lb?21 A 1 JOBSITE ADDRESS ug .( OWNER'S NAME t R � �� POWNER ADDRESS (vo' (JS' D TELT��JIFAX f TYPE OR OCCUPANCY TYPE COMMERCIAL( (I EDUCATIONAL Q RESIDENTIAL[J] PRINT CLEARLY NEW: RENOVATION:D( REPLACEMENT:© PLANS SUBMITTED: YES Q NOE FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM 11= DEDICATED GREASE SYSTEM �_ _..__ ___.i _j DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER __._. I _ I __ _ .__J } DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 114-4JA LAVATORY ROOF DRAIN. I � I t I J _ _.! J SHOWER STALL ( ___J __..moi __ f _ _._ } .___ _. — SERVICE/MOP SINK T61LET U INAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: 1 have a current liabi i v insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO Q [� IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW r LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY D BOND Dj 4! OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER R AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge S and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent rovision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4- 64q � P, � PLUMBER'S NAME (LICENSE# 3- ( SIGNATURE IMP© JP Eli CORPORATIONb1# F7Z {PARTNERSHIP®#=LLC -(� COMPANY NAME vab✓t�l '�urm,,� �au Biu I ADDRESS CITY�� .. _I STATE ZIP 0 7�f°�/ TEL FAX 1P-GP-37j-CELL �yFiy—��� j EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION X02tS Yes No % THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# I PLAN REVIEW NOTES ~ The Commonwealth of Massachusetts - Department of IndustrialAccidihis Office of Investigations 600 Washington Street Boston,MA 02111 k9i www.mass.gov1dia Workers' compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly_ Name(Business/Organization/Individual): Address: IC ,eW 614-v i ew 4%,'d- City/State/Zip: p o-Ct*v4r,,� //,4 d!-filly Phone#: G17f 4 A�� Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 3 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.* �• [M Remodeling ship and'have no employees These sub-contractors have 8. E]Demolition working for me in any capacity. workers'comp.insurance. 9. []Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.RU Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' 13.[i Other comp.insurance required.] *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. tContractors 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: , -►vn cites w�v �' 4624a,17 C� 't ' 7NS � �� c4 Policy#or Self-ins.Lic.#: //8V— 73 r-7 d9f-7 '" 03 Expiration Date: Job Site Address: 40 D z;7'r "'0 City/State/Zip: /U� novoa�� 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 the pains and penalties of perjury that the information provided above is true and correct. Si ature: r Date: Tom- f 3 Z_01z1,, 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#: r � 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 qny 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 °° p �§ ( ) 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-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 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 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 COMM011wealtli of Massachvsetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston.,MA.02111 Tel,#617-727-4900 ext 406 or 1-877:MASSAFB Revised 5-26-05 Fax#617-727-7749 _ W.TXraSS,�o�/dla 1 I i COMMONWEALTH OF MASSACHUSETTS - COMMONWEALTH OF MASSACHUS TTS .� . . PLUME ERS Af%1D GASFITTERS PLUMBERS AND GASFtTTER5 REGtST LICENSED AS A MAST,'? PLUMBER EI t D ASA PLUMBING CORP ISSUES THE ABOVE LICENSE TO: ISSUES THE ABOVE LICENSE TO: MICHAEL C CUSCIA : MICHAEL C t:USCIA V MODERN MEC HANICIAL CONTRACTOR 18 RIVERVIEW AVE 18 RIVERV7 ,:W AVE METHUEN MA 0184 - 1910 METHUEN 04 01844- 1910 7380 05/01/14 .160742 2976 05/01"'14 160741 Fold.Then Detach Aong All Perforations Fold.Then Detach Along All Perforations Date...... .. ........................ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 14U ``�, t h C, S C, This certifies that ............................................................ ........................................................ has permission for gasinstallation "-A-4 e 1,1/ 4-el .4.., ............................................... in the buildings of... . ..... 6,S.1��cp4 at 16.66................ ..................'y North Andover, Mass. .......... Fee...7.7.-:.......... Lic. No.7,-'A-16...... **'***................................ GAS INSPECTOR Check# ; o - �� 670 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE d' 3 ZulK_ PERMIT# JOBSITE ADDRESS 1040 a re'ovfP Xr ILV w:--�JJ OWNER'S NAME GOWNER ADDRESS .rr 9-1—wo -L TEIFAX I TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:L4 REPLACEMENT:® PLANS SUBMITTED: YES FO NO F APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ( I BOOSTER E:: ,_ _� CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE - GENERATOR GRILLE INFRARED HEATER — T- —1 —. - -==--- - LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER — UNVENTED ROOM HEATE WATER HEATER ( J OTHER - - v-a�. _ INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY © BOND �] OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT O °5 SIGNATURE OF OWNER OR AGENT —" hereby certify that all of the details and information I have submitted or entered regarding this 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 SII Pertprovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �`Z// G/' PLUMBER-GASFITTER NAME !_G�g�F�sZC__ cum „- _ LICENSE# �L� SIGNATURE MP D9 MGF 0 JP D JGF LPGI CORPORATION M# PARTNERSHIP 0#=LLC®#= COMPANY NAME: DDRESS CITY G 7 Hv cry _ -JI STATE�'! 1 ZIP n..l TEL 7 ' FAX 9'Jl-GfT-2)7'-11 CELL7 -f"i`v=��2! I EMA ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ �,j, f FEE: $ PERMIT# PLAN REVIEW NOTES l Y The Commonwealth of Massachusetts Department of IndustrialAccidints MMM�01 Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' ,Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information y Please Print Legibly Name(Business/Organization/Individual): /to-V ew—l✓ c^ Address: /C Avvcrlq-.ur Ci /State/Zi �-�--� D t�- Phone#: s— .-sl 7 I`1�tu-v 14 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction o part-time).** have hired the sub-contractors employees(full and/or p ) t 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition - working forme in any capacity. workers'comp.insurance. g, (]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 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.]it employees.[No workers' 13,❑Other comp.insurance required.] *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. Iam an employer that is providing workers'compensation insurance for my employees. Below is thepolley and fob site Information, ,�-- Insurance Company Name:. C.105v— Policy#or Self-ins.Lic.#: It/6?AJ— 7- r?f 27-7 - Q 3 Expiration Date: Job Site Address: /,v 4 D e-9r 4.,4�n .rrw-a ' City/State/Zip: /VQlcy�6?-2 Attach a copy of theworkers'compensation-policy declaration page(showin the policy number and expiration date). Failure to secure coverage as requiredunder Section 21A 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certo under thepains and�prenalties of perjury that the information provided above is true and correct. Signature: ( L/ % �' C � Date- tTi- / 34 JI Phone# Zt F}-._?17 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 M COMMONWEALTH OF MASSACHUSETTS COMMONWEALTH OF MASSACHUSETTS . m... moo:.. -. . ••. �"'� ' ' PLUMBERS AND GASFITTERS PLUME ERS AMD GASFITTERS LICENSED AS A MASTk R PLUMBER REGISTEF FD ASA PLUMBING CORP ISSUES THE ABOVE LICENSE TO: ISSUES THE ABOVE LICENSE TO: c MICHAEL C CUSCIA MICHAEL C t-USCIA MODERN MEt NANI('aL CONTRACTOR 18 RIVERVIEW AVE 18 RIVERV; ;:W AVL' + METHUEN MA 0184— 1910 METHUEN X14 01844-1910 7380 05/01/14 160742 2976 05/011!.4 160741 ' oumm mg IRHt'M GA C i `� Fold.Then Detach Along All Perforations Fold,Then Detach Along All Perforations 2-1�o . J.j.� Date.................. . .............. T TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING HU This certifies,that ..................................................... ....................................................................... has permission to perform Ae...'A.—.�.......I..................................................... ...... ........... wiring in the building of.....T(.\.k.C'..Te-P.......�.PSS-;....4....... ............. ................ ......... ... ... ... .... .... ................ at .....V)W...... -North Andover,Mass. Fee... ............... ..............Lic.No ..............L C� �I S. ELEt4cAL iNsp=OR V Check# G, Commonwealth of Massachusetts Official Use O y Permit No. Department of Fire Services Occupancy and Fee Checked s BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leave blank �M APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),527 CMR 12.00 (PLEASE PRINT IN.INK OR TYPE ALL INFORMATION) Date: Ie—h. t ) —T City or Town of: NORTH ANDOVER To the Inspector o WYires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) c o s v Owner or Tenant �a C rte Telephone No. — Owner's Address Is this permit in conjunction with a building permit?� Y�s No F] (Check Appropriate Box) Purpose of Building �"7 Utility Authorization No. - Existing Service Amp&.W 00 Overhead❑ Undgrd[:1 No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ``letf w rdt/ 1 `jLLor Completion of the following table may be waived by 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 A No.of Luminaires Swimming Pool Above ❑ In- El o Emergency Lighting. rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS 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/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection No.of Dryers Heating Appliances KW Security Systems:* 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 Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: ) 11/ Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVE 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 cover>ws in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,ander the pains and penalties of perjury,that the%normation on this application is true and complete. FIRM NAME: . -r a v S ,C Gc LIC.NO.: j I Licensee: ,r �� Signature LTC.NO.: (If applicable,eLn er "e ,,,in t e license numb r line Bus.Tel.No.• , Address: �'l2� _ t'I' 7� !7 Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security 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. 1��— n� ❑ 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 r "� 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 0 Failed IN Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass N Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: r Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH SPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Y Inspectors Signature: — Date: FINAL INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspector Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidints 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 NaMC(Business/Organization/Individual): 1111ae, 5t-_eV-0E, ae,27--!ej Address: m 7 /d'M f,�re- City/State/Zip: 4V e �� /�P/ Phone Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction e oyees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and'haveno employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.01 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.]t employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they Lire doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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:. Policy#or Self-ins.Lic.#: 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 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. Y do hereby certi a al ' jury that the information provided abo a is true and correct. Si ature 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.PIumbing Inspector 6.Other - - - Contact Person: Phone#: i v:► II . r 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'ofhire, 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 x 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 he. 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,ss teleph one and fax number: • t Tho COMMORwoalth of Massachusetts - Depaftent of JAdustdal.A.ccide-ats Office.ofInvesftaiions 6.00 Washingtof.Stxoet Boston,MA 02111 Tel#617-7274900 opt 406 or 1-877:MASSAFE Revised 5-26-05 Fay,#617-727-7749 WWW-Mass,govfdia ti ♦J• ::;COMMONWEALTH OF M:,... I E :ECTRICIANS<>< ;<:>< G. 1'SSUES THE.JOLLOWING L >CENSE A FR7=D MASTER :LECTR I G:I A wAL;TER E DAVIS y 4 142 PR f' IR'f15E` STR t .Al/£RH I LL <;,>;«:" A.. 01830-49 `'x+>;>:.: 660 t:> > > 07/3 ;/ ;6 27199