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HomeMy WebLinkAboutMiscellaneous - 11 TYLER ROAD 4/30/2018Date .... b� ....... . ... ......................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...0�......eR4 �.....)A...................................................................................................... has permission to perform ... P .... b ... . . -) V'Y) ..................................................................... ....... ..... ........ , � �- 4z� wiringin the building of ........................C....- ................................................................................... at ....... I ... I ........ 7;1I.na .......... e. J ......... ..... .... W, rth Andover, Mass. ............. . ... ...... ..... ...... '2 14�4 Fee Lic. No. ... ... . ... .. . ...... .............. a ................................................ LECTRICAL INSPECTOR Check# 9 6-1� — in, -7 1 t I \1) 1 bo— 2t-lk HI? S4 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. �1000' Occupancy and Fee Checked ,M BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07j (leaveblank 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 NK OR TYPE ALL INFORMATION) Date: t?— j 2 f 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) f % ry ler k .` ) Owner or Tenant , Owner's Address 4�p No. of Total Transformers KVA Telephone No. No. of Hot Tubs c Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) o Emergency Lighting Battery Units Purpose of Building No. of Oil Burners cam. Utilit Authorization No. L® No. of Zones - Existing Service 460 Amps f20/ Je ci4olts Overhead Undgrd ❑ No. of Meters i `1 New Service 2,00 Amps / ZQ / Z YQiolts Overhead FV4"*� Undgrd ❑ No. of Meters N Number of Feeders and Ampacity No. of Self -Contained Devices No. of Dishwashers C Space/Area Heating KW Location and,Nature of Propued Electrical Work: ® 0 �(er No. of Water KW Heaters No. of No. of Signs Ballasts —xyn if c �i v Gv .S° 110 e OTHER: Completion of the following table may be waived by the Ins ector of Wires. .4f 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- El rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of SwitchesNo. /JXInitiating of Gas Burners No. of Detection and / Devices (U No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers t Heat Pump Totals: Number Tons KW ......................Detection4&lerting No. of Self -Contained Devices No. of Dishwashers C Space/Area Heating KW Localunicipal FJOther Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent 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 cov rage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [V BOND ❑ OTHER ❑ (Specify:) I certify, atnder the=ainsad�nenaltiesfperjury, fiat the information ori this application is true and complete.FIRMN :�Iel' �°Iec, - I G fV> GE? LIC.NO.: 2%'Z C3 Licensee• AFAI, ^4— r' � A— —6 1 f-'�f"nature O • I _ £ g (If applicable, enter "exempt" in the license number line.) L Bus. Tel. No.. •174'4 Zq Address: /' [�_�( �a11 f e q�%E✓!l� Alt. Tel. No.: *Per M.G.L c. 147, s. 7-61, 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. ❑ 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 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 .1 i 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 M Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PART UGH INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature. Date: ROUGH INSP CTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: �/� -Z.X-= / Inspectors Signature: Date: -3l /S— FINAL INSPE ION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: /L—/ DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com !V. h The Commonwealth of Massachusetts Department ofIndustrialAccidents 1 Congress Street, Suite 100 Boston, MA. 02114-2017 www.mass.gov/dia . 7 ODM SV' V9 Workers, Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Orgaiaation/Indi dual): Address: City/State/Zip: Phone #: q Z Are you an employer? Check the appropriate box: 1.�I`am a employer with_employees (full and"' part-time). 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. (No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. F1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. S. ❑I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance) 6. ❑ We are a corporatiori and its, officers have exercised their right of exemption per MGL c. 152 § 1(4), and we Have no employees. [No workers' comp. insurance required.] g3oz9 Type of project ()required); 7. [j New'd'onstruct[on 8. [] Remodeliing 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12. g Plumbing repairs or additions 11E] Ro6f repairs 14. [] Other *Any applicant that check's box#1 must also filln: out the section below showing their workers' compensation policy informatio 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' n additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing -workers' compensation insurance for• my employees. Below is the policy and job site information. Insurance Company lame' Expiration Date: Policy # or Self -ins. Lic. #: . City/State/Zip: Job Site Address: policy declaration page (showing the policy number and expiration date). Attach a copy of the workers' compensation Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a firie up to $1,500.00 and/ox 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 be forwarded to the Office of Investigations of the DIA for insurance day against the violator. A copy of this statement may coverage verification. I do hereby certify under thepains and penalties ofperjury that the information provided above is true nd correct. /� � Datc• _CI' I-) Y - 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): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone #: Contact Person: 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 enferpri'se, 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 ofthe 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 intp 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 certificates) 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia OF Date .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ........................................................................................................ has permission to perform J) ...................................... wiring in the building of ................ ....c .......4........................................................ G J1 at ............./ � / ...... lzr�le . ....... ...... ............................. . Nghih. Andover, Mass. Fee .... . .......... Lic. No................ �LECTRICALINSPECTOR Check # 1 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. /,;-' 7 3 �— Occupancy and Fee Checked [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 CMR 12.00 (PLEASE PRINT INMK OR TYPE ALL INFORMATION) Date: I 3,1.- / `j City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intelption to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address �Q (Yk Is this permit in conjunction with a building permit? Purpose of Building - Existing Service Amps / Volts New Service Amps / Volts Telephone No. Yes [5 No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1 r Db ' f —p Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires `Z 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- Elo. rnd. rnd. o mergency Lighting Battery Units No. of Receptacle Outlets �� No. of Oil Burners FIRE ALARMS No. of Zones No. of SwitchesNo. I of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number I Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances KW SecN . o Devices or Equivalent No. of Water Heaters KW No. of No. of Signs Ballasts Data Wiring: 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: 1NSURA-NCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under thepa{ns and It' of�pe,�'u y, Vial the information on this application is true and complete. FIRM NAME: G� �� C:� ��i"��C 3 e��/� CSP LIC. NO.:_2_� 7 J Licensee: JC0b be/ -r, ! �fi ( f-/ Signature LIC.NO.: (If applicable, enter "exem t" in the license number line) � Bus. Tel. No.:q...2 f - % Address: !a � 10 J <ct le1�.1 C�`- �' 3Q 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. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the q permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed ,p' 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 conceming 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 (] Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP ION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSP ION: Pass M V Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: --- DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com k ^1 v The Commonwealth of Massachusetts :. 0 Department oflndustrialAceldents I Congress Street, Suite 100 Boston, MA 02114-2017 qr www.massgov/dia oM s��V Workers, Compensation Insurance Affidavit: Builders/Contxactoxs/Electricians/I'Inmbers. TO BE FILED WITH THE PERMITT'NG AUTHORITY. Name (Business/Orgai&ation/lndividual): Address: 7,O, f.� 0" City/State/Zip: JVt c� he 3 6 Z f Phone #: Are yo n employer? Check the appropriate box: 1. I am a employer with employees (fitll and/or part-time). 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑I am a general contractq and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. ❑ We are a corporation and its, officers have exercised their right of exemption per MGL c. 152 § 1(4) and w , have no employees. [No workers' comp. insurance required.] M_�77—/`/l Type of. project (required): 7. [1 New'd6nstr6ci[on 8. E] Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12,; [f Piwnbing repairs or additions IIEJ Ro6£repairs 14. [] Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information: 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" box must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy ## or Self -ins. 1,10 - Expiration Date: City/State/Zip: Job Site Address: policy declaration page (showing the policy number and expiration date). Attach a copy of the workers, compensation Failure to secure coverage as requited under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 enalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a and/or one-year imprisonment, as well as civil p day against the violator. A copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. Ido herehy certify under thepains andpenalties of perjury that the information provided above is true and correct. r -i A 2 Date: � l `� — L/ -)Cr— / 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): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: `a e 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 hix'e, 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 receivet'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 b6 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 certificates) 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. i3e 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 thai 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAFE Fax # 617-727-7749 Revised 02-23-15 www.m.ass.gov/dia COMMONWEALTH OF MASSACHUSETTS BOARD OF ELECTRICIANS E: I< ISSUES THE,FOLLOWING LICENSE AS A J t REGISTERED MASTER; ELECTRICIAN IRORERT F CHANDLER 15 A AVE \ 'W ► iSALEMNH 03079-2504 21468.A 07/31/16 53470 Date ... 71-rll� ................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... ...... �Pr.N..g� ................................................................... has permission to perform .... ... .. .... .............. �j \j wiring in the building of ........ C.!..c�,weg . ................................................................. at ....... .......... .................................. ye,-Yorth Andover, Mass. Fee.,4t) ... := ......... Lic. No. ....... ... .. .. .. ELE A- L- TOR Check # 1-I- (A -()l 1 I '.. :�.. - Q (forrunonwea& of Mai9aclwetb Official Use Only cc�� c7 Permit No. ( 0 aL.Jepart`ment` o� _tire �erviced Occupancy and Fee Checked p BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/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 ALL INFORMATION) Date: -SLi y a — 2_01!J City or Town of. NORTH AKDCNER, 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) aLs\tE 4 TYLER. Q_ IAn I WPV*4 46 1 Owner or Tenant -,r -yr C34 (_C Rr Telephone No. 978 6EZ 75 Owner's Address 5 M F Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work:-Lg=�N� 'FyRENDER.a) S. ny� .. l�Ew�.R►'E of ICStAE_ NEW in l _ T=RIED Fi 3RNIA C E - Com letion of the followingtable ma be waived b the Ins ector o 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 Swimming Pool Above ❑ In- El rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. o Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons 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 Connection No. of Dryers Heating Appliances K Security Systems:*KW No. of Devices or Equivalent No. of WaterNo. Kms, 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: 1 —%k 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 thepains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: —r -LM WYNN F SignatureEtun;aLIC. NO.: (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: Address: jS_ [.,AI F Nx 1 .LAr F RM. WE: &I TON NH o' 5'S 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 a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ F 3 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, ISA 02111 awww.m ass.gov/Mita Workers' Colinpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aiimlicant Information Please Print Legibly Name (Business/Organization/Individual): "T!.J%A i - IV_J. 0. Address: 15 e--IALP--VML_J AC -OF— R D City/State/Zi hone #: 9"18 7714 G Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* T am a sole proprietor or partner - hip and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.1r-1 Roof repairs 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. tContrictors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. 1 lien an employer that is providing workers' compensation insurance for nay employees. Below is the policy and job site information_ Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: M TYLER Rn. IJaRTR ANUOYM City/State/Zip: MA n18445 Attach a copy of the workers' compensation policy declarations 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 sander the pains sand penn_lties of peJury that the information provided above is true sand correct. Phone #: 97,x_9, C1 L4 fo221 Official use only. Do not write in this area, to be completed by city or town officiat City or Town: Permit/License # Issuing Authority (circle once): 1. Board of Health 2. Building Department 3. City/Towns Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 1 1. Location No. 1 Z Date Z TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ �J Foundation Permit Fee $ Other Permit Fee Sewer Connection Fee Water Connection Fee TOTAL W�7/17196 1]:27 1.03 / ` 65.00 PAI wlding Inspector Div. 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Z > LL N N : LL LL� o w w O u=. � �p F p0e ° oi� ¢ y no00z O N 0 0 oczz 0 0 l 0 3 2 �� oa0 C) O 'o< m co W W z doe a N uuY zuW n f+! W m 11 ¢ a m oa vdopx aO o W mo OuOu ?�u�z�z0� N W m as<NO� ¢ppoW•a 0 J oe tp o O °C -W iW0 o P i« N!� ¢ pU pV m d Q �ZI2 V 3 ¢ Q> NHa�Om OU NN l�i9LL Q Zi wFa-a LUGA I IUdV: i 1 I rLcr< r'�Uriu CITY, STATE. NORTH ANDOVER, MA UCLL)1GEI-R T. PLAN REF: r 1l 14650F/- sir. 4054/162 1780 TYLER ROAD 1994 (c) Boston Survey Software PREPARED: 08-16-1995 SCALE: 1 inch = 30 feet CERTIFIED TO: FIRST ESSEX BANK, FSB The permanent structures are approximately located on the According to Federal Emergency Management Agency ground as shown. They either conformed to the setback ���N OF A44 s� maps, the major improvements on this property fall in an requirements of the local zoning ordinances in effect at .1► O the time of construction, or are exempt from violation en- ��� CARMENy�v'�, ea designated as Zone C-1 forcement action under M.G.L. Title VII. Chapter 40 A, A. � A. y Community Panel No: z'po Q' �� -_ pOo 3' C Section 7, and that there are no encroachments of major TESTA improvements either way across property lines except as Effective Date: 6—Z,—`?3 shown and noted hereon. p o No. 18467 C is areae of minimal flooding (no shading). This 90 9 Fr;,.._�a� .o'o� ote: Zone L eeiQnation is not based on an elevation certificate. 0 ,\ ✓k vrnorU�secz��t o�✓2 /auae Restricted To':.. 15 - ( DEPA<RTHENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE 00 - lone Number: Ezpires: Birthd3-e;! ° lA - Kasonry only CS 749212 01/31/1998 01i31119:2 ' 1G - 1 s ? Family Homes Restricted To: 1G Failure to possess a current edition of th q#assachusetts State Buil' di nq Code WILLIA14 R CLARK 3R is cause for revocation of this license. 16 LYNDALE AVE HETHUEN, "RA 01844 HOME IMPROVEMENT CONTRACTOR a j j Registration 106563 Type - INDIVIDUAL Expiration 07/24/98 CLARK REMODELING William R. 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'ry4�, .., . ,_ . -a ,..., ,`.- - - � .. - ., � ��•• � v NSW $ y'nrn c CD =om \ -4 -4 N N 00> (02 -4 --&-G) M r rn c rn rn �iv z :41x I T C wK mo –4 a'p D -co TN to C, T; r ,tea y .- , t.Y _ • • •� r .4.j 4ti ,e ec. .t t \e•.1! _; '� Srq�t ��7 4..f \ \' i o � - } f '� i. Jrr T a NY < S 1 j.�, 1. 14' �q �cli: T. +�iS ♦ 7 \ ���nr�;4?� ._ .t c:�h�-'�. 'ry4�, .., . ,_ . -a ,..., ,`.- - - � .. - ., � ��•• Jackson Lumber & Millwork F -1MON. TUE. WED. THU. FRI. SAT. LOADED AND CHECKED BY DRIVER ❑ ❑ ❑ ❑ ❑ ❑ ❑ A.M. ❑ DELIVER ❑ P.M. ❑ PICK-UP STORE HOURS MON. THRU FRI. SAT. 7 A.M. - 5:30 P.M. 7 A.M. - 4 P.M. JACKSON LUMBER & MILLWORK CO., INC. We agree to furnish the below material for the sum indicated in the "TOTAL AMOU T' box. Compare your 215 MARKET STREET • P.O. BOX 449 • LAWRENCE, MA 01842 list carefully. We furnish no items not specifically mentioned. Prices subject to eptance within SEVEN PHONE (508) 686-4141 FAX (508) 688-6802 STORE days and delivered within 30 days from the date hereof. Customer agrees top a restocking charge on all returned items of fifteen percent (15%) unless returned material was damag upon receipt by customer. (508) 688-6844 OFFICE TERMS & CONDITIONS - SEE REVERSE SIDE QUOTATION I HAVE A NICE DAY I /JACKSON LER/MLWK SOLD SHIP TO: (SAME AS S(46 TO UNLESS NOTED BELOW) TO: QUOTE CUSTOMER JOHN A 1 JILL PINNOLA 215 MARKET 'STREET 11 TY R RD NCRT ANDOVER, MA LAWRENCE MA 01843- Customer Code Sequence No. Time Salesman 65859 7 70194 UM — 1.11 1 PAT PAtMESE EXTENSION Date Wanted 55859 Transaction Date 70794 Store No. 1 S'man. 3 r. No. 33 1/ 0 4 1 1251- 7/14/94 CABINETRY AS P R PL.AN A Reference Number Customer Order Number Ship Via Terms Salesman 65859 7 70194 UM — 1.11 1 PAT PAtMESE LN# ITEM NUMBER OUAN.ORD. DUAN. SHP. DESCRIPTI N UM PRICEIUNIT EXTENSION rl XiL •+t LA r 2 1433. V_U ...,'733. uv CABINETRY AS P R PL.AN A r AAT+ $1557.15 FOR CORIAN COUNTERTOP IN SIERRA SERIES FOR ABOVE. FABRICATION, INSTALLA ION, AND TAX I14CLUDE I I. ADD a2 5.70 FOR SQUARE EDGE COUNT TOPS IN YOUR CHOICE OF STOC` COLORS FOR ABOVE# TAX NCLUDED. )W42 INSTALL.. 1 IN TALLATION OF CABINETRY Ei 2,524#0 2,524.00 3 SOBLDGPRD 1 MATERIALS FOR INSTALLATION E 200.0 200.00 t CA?jINET 11-EMOVAL_ t� SPOSAL_ ? s-rh _ ' U Q DEZvtYMenjr J dgb p f -,q UJAct..L 0 L t� c.�w� Mot•(>QCj -201� GovKh'st: P I ELIE TSI .t CC, s PERM �rC, 3 33 IF SPECIAL ORDERED, I UNDERSTAND THAT THE ITEMS LISTED SUB -TOTAL TAX% AMOUNT• ARE CORRECT AND NONRETURNABLE. 5Y257.00 J% 131#5 5,368.5T, ACCEPTED BY DATE # 000 OFFICE COPY m�ViO> C m r N 4CD EDCD r N m qoz- 0M-4>c m 2z0Ovzi "4>mz0 ;Flm z (nC TON 4> -,mz m 0 z O ZZ>y - tOMN 1 Ozmm i' 0 0 � n 0 0 4 m�20Nm ODOR;mcn C m n WZ I m Z m�Z:�-0 Z " Z- �-n> z x --4 (n I 0— m h> Oimm'rm '0�NOpz'D M;Om--4I F. Oo< Or- MOD Q�Z(nI0 `zNra; -t D>�� Om�>� Or. 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