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HomeMy WebLinkAboutMiscellaneous - 107 WAVERLY ROAD 4/30/2018 (3)/— -I -/ I � 15� Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......................................................... . .............................. has permission to perform .. 111--111-11�C�1-1- ............................................................................. wiring in the building of ......... A . . .................. jk� ....................................... at.Z41 ......... .......... ��,,.North.Andov9�,,Mass. Feec. M475;2 ................. ..... ..... . ....... . . ... .......... ..................... Li R Check # / 3 ELEMICAL INSPE it MM iy aJ Commonwealth o f Masaac4ueetb Official Use Only Apartment partment o f —7ire Serviced Permit No. F1 R/ _ od Occupancy and Fee Checked /O t , = BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] up, ] 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 PRINT IN INK OR TYPE A L IN FTION Date: /-5-- l Q City or Town of: w�r-� 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) / 1�1 7 Z /7d/ Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Purpose of Building (Check Appropriate Box) Utility Authorization No. Existing Service x,60 Amps IZa / 2 -Vo Volts. Overhead ©- Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: r e— Gig No. of Meters 21 No. of Meters Completion of the following table may be waived by the InSDector of Wires. No. of Recessed Luminaires ! No. of Ceil: Susp. (Paddle) Fans Z- No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool ❑ ❑ o. o Emergency Lighting J` rnd. rnd. Battery Units No. of Receptacle Outlets 26/ 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 Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Number TonsKW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances K KW Security Systems:* 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 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: 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 co rage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under t e pains and penalties of per'ury, that the information on this application is true and complete. FIRM NA p�� _f + s—j LIC. NO.: Licensee: L /-'f(l �r Signature ?, LIC. NO.: (If applicable, enter " xempt" in the license number line.) // Bus. Tel. No.: Address: — �1�V - SG, � WL �%7 0 3D7 Alt. Tel. No.:�4i *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 Signature Telephone No. �� PERMIT FEE: $ Date ... .... ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... :�Z ......... /.�- ...................................... has permission to perform .............................. wiring in the building of .: ...... ��117.—�.. .............................................. at ... e�cl ....... lz--:�r ........ ... North Andover, Mass. Fee............. Lic. No . ............. ......... ... C� LE RI �AL IiN�S�E�(fR Check # 0 t `� 0 4 i\ CommoiewJ4 of Maejach.eff, cc77 eUePartmed of - ire �eraice9 BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 911 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 PRINT IN INK OR TYPE 4LL 1W�0JWTION) Date: _ �-d g City or Town of. A)Q 0 �k )Ver 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 (Sheet & Number) .0 % Wrl,i rc �, A Tia Owner or Tenant - ilc�' r - t Owner's Address i6-7 wcwt S[ Telephone N Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) P f ' r,7�, I' us pose o Building pn t 9a5 P ,Qt Utility Authorization No. Existing Service ZoU Amps rL� / GL Volts Overhead Undgrd E]New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Meters No. of Meters attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of El�Jctrical Work: 0b (When required by municipal policy.) Work to Start: �� /3 (G 5 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 suchcov age is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify, under thepains and eihalttes ofperjury, that the information on this application is true and complete. FIRM NAM: QUt V �— S -(l i LIC. NO.: D9 Z I E Licensee: GU i A Q.S S-1 / Signature ,,.'-t LC LIC. NO.: 3, z F (If applicable, enter "exempt" in the license numbe� line.) Bus. Tel. No..SOJ�-,TZI ` l go Address: }r{ IS SUtH S 7 ��/�� Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requir s 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, l hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ u ejuhuwing rume may oe waivea by the Ins ector o Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KV No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- El O.o mergency ig ung rnd. rnd. Batte 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 Initiatine Devices No. of Ranges No. of Air Cond. To Ton sl No. of Alerting Devices No. of Waste Disposers Heat Pum Number Tons KW ............."'..... No. of Self -Contained Totals Detection/Alertin gy Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Waters No. of No. of No. of Devices or E uivalent KW HeaterSi ns Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wirin g: No. of Devices or E uivalent OTHER: attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of El�Jctrical Work: 0b (When required by municipal policy.) Work to Start: �� /3 (G 5 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 suchcov age is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify, under thepains and eihalttes ofperjury, that the information on this application is true and complete. FIRM NAM: QUt V �— S -(l i LIC. NO.: D9 Z I E Licensee: GU i A Q.S S-1 / Signature ,,.'-t LC LIC. NO.: 3, z F (If applicable, enter "exempt" in the license numbe� line.) Bus. Tel. No..SOJ�-,TZI ` l go Address: }r{ IS SUtH S 7 ��/�� Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requir s 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, l hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ ELECTRICAL Residential (1 & 2 Family) New Construction (1 & 2 Family) 0 - 2,500 S.F. Each Additional 1,000 S.F. Alterations/Additions Single Family Service Change Up to 200 amp. 300 amp. 400 amp. Vinyl Siding Above Ground Pool Inground Pool Alarm Systems Appliance Replacement Work w/Out Permit Re -Inspection Fee $300 , $100 $15/$1,000 + $40 Base Fee $70 $140 $210 $55 $70 $100 $70 $55 Double Permit Fee $40 Commercial (including 3 Family) New Construction (Including 3 Family) Alterations/Additions $18/$1,000 + $50 Base Fee 2- ELECTRICAL Cellular Tower $500 $500 Cellular Tower Equipment Room Cellular Antenna (New or Replacement) $500/Antenna (Up to 5 Antenna) Cellular Antenna (New or Replacement) $1,000/Antenna (Six Antenna & Above) Tele -Communication Systems $50 + $1.50/Drop (1-25 Drops) Gerald Graham $50 + $18/$1,000 (26+ Drops) Group Metering 1st Meter $150 Additional Meters $50/Meter Work w/Out Permit Double Permit Fee Annual Maintenance Permit $250 Re -Inspection Fee NOTE: CERTAIN APPLIANCE REPLACEMENT $50 REQUIRES PLUMBING PERMIT! TOWN OF BRAINTREE p4 RAfyT Depart=nt Of Licenses Municipal and Inspections $9ss -4 CgUs�' Gerald Graham INSPECTOR OF WIRES OFFICE HOURS: 8:OOAM - 9:30AM AND 1:00PM - 2:OOPM 90 Pond Street Braintree, MA 02184-6498 Tel. 781 .794.8075 ggraham@braintreema.gov Fax 781.794.8022 D ate A/M/ ( �/. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .... �, ............ . /t . t C . �1- . // ( . . ' . . . . . . . . . . . . . . . . . has permission to perform .... P�' plumbing in the buildings of . ...................... at -North Andover, Mass. Fee. 0 ..... Lic. No..F/ 71.c .. ....... ......... /PLUMBING INSPECTOR Check # 83210 MASSACHUSETTS UNIFORM "PLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location %v n` V C I Owner I L C) 13"` F'/i fq (` New 0 Renovation Replacement rw�rrm►r, o Plans Submitted yes Date b Permit # 3 t o Amount Y ),~ & No (Print �`1n Co J �!�' i I� Fv C Check C e: Date Installing Company Name /` • Address l °Z' 7 A R 6 o 7-T 3-r L A Partner. Business Telephone Firm/Co. Name of Licensed Plumber: /,�,C R A 7 /y1 A ^')' I Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy [:k Other type of indemnity Bond Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations pert ander permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts St� Plum Cod 142 of the General Laws. D (OFFICE USE ONLY ,;ypr of PIumBiag License aZ CA rcense Number Master Joumevman j-1 P The Commonwealth ofMassachusetts 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 Pplicant Information Name (Business/Organization/individual): �� %� K -T, Address: City/State/Zip: A VA/ M A©/,�VPhone #: NG . Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. E] Demolition 9. ❑ Building addition 10-ElElectricalrepairs or additions 11. [plumbing repairs or additions 12.[] Roof repairs 13. ❑ Other ---D= 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 workerscompensation insurance for my employees. Below is the policy and job site information. 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 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 underVe pains and penalties of perjury that the information provided above is true and correct Si ature: Date: 1A lip I CP41 Phone #: 7r0 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 #: Aou an employer? Check the appropriate box: y1. am a employer with 4. ❑ I am a general contractor employees (full and/or part-time).* 2. ❑ I am a sole proprietor or and I have hired the sub -contractors listed partner- on the attached sheet 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 required.] 3. ❑ I am a homeowner doing and its officers have exercised their all work myself. [No workers' comp, right of exemption per MGL c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] `Amy applicant that cheeks box #1 must also fill out the section below shoain.- - "-e their WC yam' t Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. E] Demolition 9. ❑ Building addition 10-ElElectricalrepairs or additions 11. [plumbing repairs or additions 12.[] Roof repairs 13. ❑ Other ---D= 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 workerscompensation insurance for my employees. Below is the policy and job site information. 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 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 underVe pains and penalties of perjury that the information provided above is true and correct Si ature: Date: 1A lip I CP41 Phone #: 7r0 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 #: 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 -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 gar 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 Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass-gov/dia Fk k+t I Q I \N A E- PU- NOV-D-i ANIJUA�K 4 13 k o" F i�- t"i A,, t 0 Coo E k. le Lz V t;Zueeev'l t. '61, A I=ii' e: %,3 1-1+ 0 is P S E f- B E Lzn'-i j�AoL k,Al ek 4 CV- iLA AJ C- L,, 15- '�:Z p c;� Lawrence H. Ogden P.E. 198 East Main St Georgetown, MA 01833