HomeMy WebLinkAboutMiscellaneous - 113 CHESTNUT STREET 4/30/2018 c h e 113 CHESTNUT STREET
210/060.C-0027-0000.0 -
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2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the l
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed _ f/
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 ofongoing construction activity,and may be-deemed-by thelnspector_of_Wires abandoned.and.inv.alid 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
puipose 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 15,20008 and extending"through August 15,2012.
ule 8—PermitAl)ate Closed: elf--/ ***Note:Reapply for new perm
0 Permit Extension Act—Permit/Date Closed:
7-
1,0 172 Date..................................
f NGRTM 1
TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
�,SSACHUS�
This certifies that f!<.4.�%.4.7................ ` `.
....... .... ...... ..............................
has permission to perform ........^%!.'
2............� ....."
wiring in the building of &..e..... h-
3.......�..?..*. .T!y..`. ........ ,North Andoxer,M
Fee.....Z.j Lic.No r ..... ....1�... . . �v`:t'!'r ....
ELECTRICAL I;SPA
Check # O��
Commonwealth of Massachusetts
Official Use Only
®epartment of Fire Services Fe
la/ 7 Z
BOARD OF FIRE PREVENTION REGULATIONS and Fee Checked
(leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL
All work to be performed in accordance with the Massachusetts WORK
®R I�
Electrical Code
(PLEASE PRIMT flV AW OR (MEC),527 CMR 12.00
�E'ALL IIVFORMATIO
City or Town of: NORTH ANDOVER Date: f =�
By this application the undersigned gives notice of his or her intenti to perform theTo the p electrical wk dqtor of ies nbed below.
Location(Street&Number) 3
Owner or Tenant
Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? yes
� NO El (Check Appropriate Box)
Purpose of Building
- Utility Authorization No.
Existing Service Amps _ / _volts
Overhead ❑ Undgrd❑ No.of Meters
New_ Service Amps _volts
Overhead EJ Undgrd❑ No,of Meters
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work:
1st-- 0%_ r1�,1„_
j Com letion of the ollowin table maybe waived by the Insector of Wires.
No.of recessed Luminaires 9` No.of Cell:Susp.(Paddle)Fans No.of Total
! No.of Luminaire Outlets Transformers �7A
. No.of Hot Tubs
No.of Luminaires Generators KVA
Swimming Pool Above ❑ in- o.o mergency lg g
--, No.of Receptacle Outlets d• nd. ❑ Batter Units
No.of '
Oil Bur Burners s F_TPF AJAR . c
No.of Switches -M� No.of Tones
No.of Gas Burners IT- Detection and
No.of Ranges Initiatin Devices .
No.of Air Con d. Total
No.of Waste Disposers
Heat Pump Number Tons Tons No.of Alerting Devices
Totals: -- -•.__......_..._....................K ......_ No.of Self Contained
No.of DishwashersDetection/AMertin Devices
Space/Area Heating KW Local❑ Municipal
No.of Dryers Connection ❑ Other
�' Heating Appliances KW Secu ty Systems:*
` No.of Water No.of o.of Device
s or E uivale
Heaters �' No.of nt
Si s Ballasts. Data Wiring:
No.Hydromassage Bathtubs No.of MotorsTelNo-nf ecommunications W uiva ent
Total HP
OTHER: No.of Devices or E uivalent
a
Estimated Value of Vlectrical Work: Attach additional detail if desired,or as required by the Inspector of Wires.
_' 06.00 (When required by municipal policy
Work to Stark 74- /I Inspections to be requested in accordance with MEC Rule 10,and upon,completion.
INSURANCE CO RAGE: Unless waived by the owner,no permit for the performance of electrical work
the licensee.provides proof of liability insurance inclu owner,
may issue unless
undersigned certifies that such coverage is in force,and has exhibited proof ti same to the permit coverage or its substantial
ubstn ial equivalent. The
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER issuing
I certify, under the pains and enalties o ❑ (SPecify:)
FIRM NAME• p fP�Jury,that the information on this application is true and complete.
Licensee: LIC.NO.:
�cM�_ Signature F
(Ifapplicable,enter mp 'in the lice a nu LIC.NO• 3
tuber li �o 9
Address
ne. U
*Per M.G.L c. 147,s.57-61,securi work re wires D c° Bus.Tel.No.:
OWNER'S INSURANCE W q ePaz'timent of Public Safety"S"License: Alt.L c!No.
WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. B my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent
Owner/Age
Signature Telephone No.7'1R I— �Sl J4,C� PERMIT FEE:� �S
ELECTRICAL PERNL[T NO, INSPECTION REPORT.-
ELECTRICAL INSPECTOR-DOIUG SMALL
Y.ROUGH INSPECTION:
�.,
Passed—[ Failed—j ] Re-inspection required($50.00)-[ ]
Inspectors'comments:
(Inspectors'Signature-no initials)
Date
F
Efj
CTION; Failed—[ ] n required($50.00)-ents:
(Inspectors'Signature-no initials)
Date
3.UNDER GROUND INSPECTION:
Passed—[ ] Failed—[ ] Re-inspection required($50.00)
Inspectors' comments:
------------- j
(Inspectors'Signature-no initials)
Date
R(JGaspecto!
SERVICE:
ATIONAL GRIL: NAME:
Failed—j ] Re-inspection required($50.00)
ts:
ectors'Signature-no initials) Date
•
5.INSPECTION-OTHER:
Passed—
j ] Failed—[ ] Re-inspection required($50.00)
Inspectors' comments:
-----------------
(Inspectors'Signature-no initials) Date
DOOR TAGS ARE TO BE FILLET) OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
..400 Washington Street
Boston, MA 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Buffders/Contractors/Electricians/Plumbers
Applicant Information
Please Print l,e ibl
Name(Business/Organizationdndividual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box:
1.❑ I am a employer with q. Type of project(required):
❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t �• �E]Remodelingship and have no employeesThese sub=contractors haveworking for me in any capacity. workers'comp.insurance. 8' ' Demolition
i [No workers'comp.insurance 5. ❑ We are a corporation and its 9' ❑Building addition
required.] officers have exercise 10-0 Electrical re
d their parrs or additions
3.❑ I am a homeowner doing all work light of exemption per MGL 11.❑Plumbing repairs or additions
�=�
myself.[No workers'comp. C. 152 1
4-
§ ( ,and we have
in required.] t employees. [No workers, no 12.❑Roof repairs
comp.insurance required] 13.❑ Other
y applicant that checks box Yl must also f 1 out the section below s
umb their we+cis,compensation policy nfo �atioa
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 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:
L 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 ST
of up to$250.00 a day against the violator. Be advised that a co OP WORK ORDER and a fine
Investigations of the DIA for insurance coverage verification PY of statement may forwarded to the Office of
I do hereby certify under the pains and penalties of perjury that the information provided above is b ue and correct
Sip-nature:
Date:
Phone#:
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health Z.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector
6.Other
Contact Person•
Phone#•
9061 Date.?.`�.'.i�. . . . .
HORTM TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
�► +0+,n° O`,fig a .
,SSACMUS� 1
`�
This certifies that . . . �`.4!. . . . . . . . ... . . . . . . . . . . . . . . .
has permission to perform w
plumbing in the buildings of . ..>.�1LJ. . .�. ? `'!^ . . . . . . . . . . . . . .
at . . . . ��.e Sh l . . . . . . . . . . . . . . . . .. North Andover, Mass.
Fee. .5 C' .Lie. NoJ.4..110.1 . `.� . . . . . .
P UMBING INSP
Check # 3G 7�
i
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town: MA. Ywners
p-
Date: 0 ( Permit#
Building Location: PS`�U4
ame:
Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential,
New:❑ Alteration:❑ Renovation:❑ Replacement: Plans Submitted: Yes❑ No
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FIXTURES
DEDICATED
L z SYSTEMS
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LL F=- Q w Q Z cC z Z ,LLJ LU i a X Q ~ Q
U a CA (A o° U > > o o a Z LL
z N P W o! I N I.-
0
F-
< m m o o LL s Y g 3N N 3 3 3 0 ° Ln Q N
-SUB BSMT. Q 3
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
4T"FLOOR
ST"FLOOR
6T"FLOOR
7T"FLOOR
8T"FLOOR
Installing Company Nam G v1,( Check One Only Certificate#
Address: ty l ElCorporation
0 �
d� Ci own:Aj State /"`
❑
/ r Partnership
Business Tel: )"t—S_-33 G Fax: 7p 60?k- _?'636b
A 0-Firm/Company
Name of Licensed Plumber: ._,_�
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch,142 Yes❑ No❑
If you have checked Yes,please
eiindiic-ate the type of coverage by checking the appropriate box below.
A liability insurance policvyf'X Other type ype of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance
Massachusetts General Laws,and that my signature on this permit application waives this requiremen req by Chapter 142 of the
Check One Only
Si nature of Owner or Owner's A ent Owner ❑ Age, ❑
I hereby certify that all of the details and Information I have su itted(or entered)reg rding this application ar true d accurate to the best_ey
Knowledge and that all plumbing work and installations pert me I under the permit is ued for this a lication ill
Pertinent provision of the Massachusetts State Plumbing Co ea Chapter 142 oft in mpliance with all
Gene La
By
Type of License:
Title _lumber igna ure of Li nsed Plunifer
City/Town aster
APPROVED OFFICE USE ONLY) Journeyman License Nu er: 4 30 J
1
The Commonwealth ofMassachusetts
Department oflndustrialAccidents
b
I� Office of Investigations ,
600 Washington Street
_Boston,MA 02111
www.massg ov/dia
Workers' Compensation insur a'nce A.uidavit.JBuiiders/Contractors/FIectricians/Plumbers
Applicant Information . Please Prinh'Leg-libiy
Name(Business/Organization/Individual): �" C-1 r
Address: p
City/State/Zip:_ Q 4, .�¢. Phone##: 7 — 6k9- 33(ne
F
re you an employer?Check the appropriate box: Type of project(required):
[4I am a employer with4. ❑ I am a general contractor and Zemployees(full and/or parE-time). have hired the sub-contractors 6• ❑New construction
❑ I airy a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. n Demolition
working for mein any capacity. workers'comp.insurance. 9. Buildingaddition
[No workers' comp.insurance 5. ❑ We are a corporation and its ❑
required] officers have exercised their ME]Electrical repairs or additions
3.❑ I am a homeowner doing all work right ofexemption per MGL - 11.0 Plumbing repairs or additions
myself.[No workers'comp, c. 1,52,§1(4),and we have no 12.0 Roof repairs '
insurance required.] employees.[No workers' Un 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 are doing all work and then hire outside contractors must submit anew affidavit indicating such.'
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors aiid their Workers'comp.policy information.
X am an employer that is pro viding workers'compensafion insurance for my employees Belo w is thepolic and job site
information.
Insurance Company Name: P(-C S r !'o OAC
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: OM 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 to$250.0 against the violator. Bead se, that a copy of this statement maybe forwarded to the Office of
I estigations ofthe D for ins u ce covera verification.
g
l do ereby cert un er tit ' s cl p aloe o es ry that the information provided above is true and cot'1 ect.'
Si atu e:
Phone#:
Official use only. Do notwrite
f/` y an,tllis 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 CIerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or-on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance'
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation.affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-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 cant'workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Re advised that this affidavit maybe 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 ifyou 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
ofthe affidavit for you to fill out in the event the Office of Investigations has tocontact you regarding the applicant.
Please be sure to fill in the pennit/lieense 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 proofthat a valid affidavit is on file for future pen-nits or Licenses. Anew affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or pen-nit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The CoMnonwealth ofMassa.chusetts
DgpaAment of Industrial Accidents
Office of Investigations
600 Washington Street
13Won,MSA.02111
Tel. 617-727-4900 eat 406 or 1-877 MASS.AFE
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia
Ippolito, Mary
From: Ippolito, Mary
Sent: Thursday, August 11, 2011 12:52 PM
To: Tierney, Gail
Cc: Leathe, Brian
Subject: $156.00 BOUNCED CHECK for 113 Chestnut Street
Brian Leath, Building Inspector,just called Mr. Melilo (at his home),told him to bring us a certified bank check for that
amount ASAP. Mr. Melillo said he would.
Mary Ippolito, Building Department
Town of North Andover
1600 Osgood Street
Bldg. 20,Suite 2-36
North Andover, MA 01845
phone:978-688-9545
fax: 978-688-9542
mippolito@townofnorthandover.com
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