HomeMy WebLinkAboutMiscellaneous - 109 RALEIGH TAVERN LANE 4/30/2018 A 109 RALEIGH TAVERN LANE
210/107.A-01140000.0
Date....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .........16
...........
has permission to perform .......... .....
wiring in the building of......... .................................
at... /-7--Z-1,North Andover,Mass.
/
Fee..-/ Lic.No79- ."5.F<.............. ..
ELECTRICAL INSACTO
Check
9067
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 fil
on the prescribed form.ABer a permit application has been accepted b an Inspector of pp ed "
Y p 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-theInspector_of-Wires abandoned_and_invalid ifhe—__. ._
or she has determined that the authorized work has not commence&-or ha�et progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permit M"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 Cliapter 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.
We 8—Permit/Date Closed: `Q ***Note:Reapply for new permit
Q<
❑Permit Extension Act—Permit/Date Closed:
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. �U�'
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [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 K OR TYPE ALL INFORMATION) Date: )bj ,-) I O
City or own f: �Y o w PSV To the Inspe for of Wires:
By this applicatio he ersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) 1 co k ilelynLLiinc
Owner or Tenant L)a riti Telephone No. -
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No x BLDG PERMIT#
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
a
Location and Nature of Proposed Electrical Work: Install low voltage security system at above location
Completion of the following table may be waived by the Inspector of Wires.
t No.of Recessed Luminaires No.of CeilSusp.(Paddle)Fans No. of Total
:
Transformers KVA
No.of Luminaire Outlets No. of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above [IIn- El Battery
o Emergency g mg
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 No. of Air Cond. TotalTons No. of Alerting Devices
No. of Waste Disposers Heat Pump Number Tons KW No. of Self-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal Other
No.of Dryers Heating Appliances KW urity Systems:*No.of Devices or E uivalent1
No.of Water Kms, No.of No.of in ;
Heaters Signs Ballasts No.o eve uivalent
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: 'Q S LI)b (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 coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains andpenalties of perjury,that the information on this application is true and complete.
FIRM NAME: Brinks Home Security LIC. NO.:
Licensee: John Holmes Signature 4l- Tom_ LIC.NO.: 749C
(If applicable, enter "exempt"in the license number line.) Bus.Tel. No.: 978-657-0443
Address: 155 West Street, Suite 6 Wilmington,MA 01887 Alt.Tel.No.:
*Per M.G.L. c.147,s. 57-61,security work requires Department of Public Safety"S"License LIC.NO.: SSCO 001163
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: $ �;
0359 Date... ......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
US
This certifies that ........
...............................................
E.
has permission to perform ....... ;�P4le-&�
wiring2/
in the building of............. . . . ............................................
.J� North Andover,....
Mass.
Fee...ST' Lic.No., .. ..............
<. INCAL&'SPE(76
Check t,
Official Use Only
Commonwealth of Massachusetts
Permit No. b
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 C R12.00
(PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: Q 1
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) , �I •� �i1�� y Q t2(� LU �-�-(
Owner or Tenant 'Op-Q -b 0- Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building�i 1Y�1� �t�•2 I I N a Utility Authorization No
Existing Service 100 Amps 120 /2-4 UVolts Overhead ❑ Undgrd No.of Meters
New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
Number of Feeders and.Ampacity
Loc 'on and Nature of Proposed Electrical Work:
01hLOep,04eirSI i Cultip fec
Completion of the following table may be waived by the Inspector of Wires.
No.of Total
No.of Recessed Luminaires No.of Ceil.Susp.(Paddle),pans Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVO'
Above In- o.ot Emergency Lighting
No.of Luminaires Swimming Pool nd. ❑ rnd. ❑ Battery Units
-- No.of Receptacle Outlets INo.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. Tons TotNo.of Alerting Devices
No.of Waste Dis osers Heat Pump Number Tons J.KW No.of Self-Contained
P Totals: - -- ........... Detection/Alerting Devices
Municipal
No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ Other
No.of Dryers Heating Appliances KW Security Systems:*
rY 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:
d Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrica Work:• f�.0 0 — (When required by municipal policy.)
Work to Start:® l/ e 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 covers s in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE [/BOND ❑ OTHER ❑ (Specify:) (,J/
I certify,under 'ns and penalties of perjury,that the information on this application is true and complete.
FIRM NAME thL -S LIC.NO.: /
Licensee: Signa e LIC.NO.:E,3 a,'/y
(If applicabl�,applicablygr r" empt"in he license tuber line.) us.Tel.No.:
Address: �7` C Alt.Tel.No.:6/7-7 9Sr 3S(o
*Per M.G.L c. 147,s. 57-61,secu 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.
monwea o assac usetts
Department of Industrial Accidents
i
.., Office of Investigations
600 Washington Street
,.
Boston, MA 02111
www."xass govIdia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleotricians/Plumbers
At Plicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address:
City/State/Zip: Phone#: .
Are you an employer?Check.the appropriate box: Type of project(required):
1.❑ It am a employer with 4. ❑ I am a general contractor and I G. ❑New construction
employees(full and/or part-time)'
* have hired the sub-contractors
2.❑ I am.a.sole proprietor or partner- Iisted on the attached sheet. ❑Remodeling
ship and have no employees These su&contractors have 8. ❑Demolition
working for mein 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.❑ I arra a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself.[No•worke'rs'comp. c. 1.52, §1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers'
comp. insurance required-] 13.❑.Other
"Any applicant that checks boat#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the neame of the sub-contractors and their sverkers'den p.policy infvrmado,
law an employer that isproviding:worhers'compensadon lnsuranceformy employees: Below is thepolicy andjob site
informatlan
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). t
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 F
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
Signature: Date-
Phone#:
EaID only. Do not write in this area,to be con-.pleted by city or town official
n: Permit/License# t
hority(circle one):
Health 2.Building Department,3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son: Phone#:
Y
The Commonwealth of Massachusetts
Department ofIndustrial Accidents
Office of Investigations
600 Washington Street
Boston,MM 02111
www massgov/dia
Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Legibly
NaMc(Business/Organization/Individual):
Address: t4q *(pt *pA
City/State/Zip: 0,39Wphone#: _ t
�Are you an employer?Check the appropriate box: _
❑ I am a employer with 4. ❑ I am A eral contractor and I Type of project(required):
_Zeam
oyees(full and/or part-time).* have the sub-contractors6 ❑New construction2• a sole proprietor or partner- listede attached sliget. t �• ❑Remodeling
ship and have no employees Thesecontractors have 8. ❑Demolition
working for me in any capacity, workeomp.insurance.
[No workers' comp.insurance 5. 9• ❑Building addition
p ❑ We arrporation and its
required.] officee exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right omption per MGL 11.[]Plumbing repairs or additions
Myself [No workers' comp. c. 152 ),and we have noinsurance required.]f em to12.❑Roof repairs
p [No workers'comp, ance required.] 13.❑Other
*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 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 emp
information. loyees Below is the policy and job site
Insurance Company Name:
Policy#or Self-ins.Lie.#:
Expiration Date:
Job Site Address: Q e(
City/State/Zip: GQ� HIM S
Attach a copy of the workers' compensation policy,declaration age(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 ce t u der the pa s naltie perjury that the information provided above is true nd carrect.
Si nature. [ f I
Date: •
Phone#: 2
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing OF(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
i
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 ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority." y
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
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 F
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 your 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 G01n,u0i- wealt1-j of Massacl�nsetts
Aeparixnent of lndustrial 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.govldia
Date. . ... . .
,4ORTIy
pf14'O
�p TOWN OF NORTH ANDOVER
• PERMIT FOR GAS INSTALLATION 1
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SAC
HUSE��
This certifies that . . .� . . . ,1,t.��7:l�. !�'7/�6r G
has permission for gas installation . .! r.. . . . . . . . . . . . . . . . . . . . .
in the buildings of . .!?/�' �.,. . . . . . . . . . . . . . . . . . . . . . . . . .
at /0.--2. . .-/:Z/1 , ... . . . . .1, North Andover, Mass.
Fee. ), � Lic. No.. > . . . . . . .`t, . .
GASINSPECTOR
Check# t S
355
.�.��. ...._....... ..:..�, o`, co"'r%ar,m gar-rL.uc:AT'ION FOE PIERM17 TO DG
- j (Print or Type),I-
IV'
Iota::A Date
: — - Permit #
` �
Building Location e ( �'/ / s Nam - G
!/VY Type of Occupancy )
New ❑ Renovation ❑ Replacement Plans Submitted: Yes❑ No
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SUB—aSMT.
BASEMENT
1 ST FLOOR
2ND FLOOR
3RD FLOOR
4THFLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
STH FLOOR
Installing Company Name T A . ':C-AM ma T.r-1 a2
Check one: Certificate
Address na C u,v%4 ry L Nf, ❑ Corporation
7i U11 q qC3Partnership
Business Telephone_ 6,�7Z_c/ -7 f
O�irtn/Co.
Name of Licensed Plumber or Gas Fitter f�(�E T /�. `�A m.a t
11T"n
Fihave
RANCE COVERAGE:
a current p1' bility insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes L6?' No ❑
checked yes, please indicate the type coverage by checking the appropriate box
A liability insurance policy ,
Other type of indemnity❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner❑ Agent ❑
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the N
ed for this
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of Laws. application be in compliance with all
T of License:
Title Plumtterber of cen u or fitter C
l Journeyman License Number
N ,
BELOW FOR OFFICE USE ONLY
FINAL INSPECTION SKETCHES PROGRESS INSPECTION
FEE
N0. £-
APPLICATION FOR PERMIT TO DO GASFITTING
NAME S TYPE OF BUILDING
LOCATION OF BUILDING
1 '
PLUMBER OR GASFITTER
LIC. NO.
PERMIT GRANTED
DATE 19
� I
i I
GAS INSPECTOR