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HomeMy WebLinkAboutMiscellaneous - 115 CRICKET LANE 4/30/2018 (3) �.. S � . Date....�..j..GIs............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHU This certifies that ....i.. .................................................................................................................. has permission to perfonn ..=�:,...5e wiring in the building of........... at ... ..��c5 C e ,(:-j ............................................ ........Aorth Andover,Mass. Fee......A....................Lic.No. ELECTRICAL INSPECTOR Check# r s A Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked �M 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 ININK OR TYPE ALL RWORMAT1019 Date: 4- �Q LI 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) Owner or Tenant �e h,<< Qe 6,'` Telephone No. Owner's Address Q Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building I 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 Location and Nature of Proposed Electrical Work: -AJ 0 A C Cff S�►�� Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil: TransSusp.(Paddle)Fans Total . Trsformers KVA No.of Luminaire Outlets No,of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- El o.o Emergency Lighting rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers Totals: * •..•.........•"""".•"" "'•""••"............•••• Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No..of Dryers Heating Appliances Kir 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, —7 Attach additional detail if desired or as required by the Inspector of TOnres. 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: INSURANCE BO ❑ OTHER ❑ (Specify:) I'certify, tinder thepains andp naltiesqrfperjmy,that the information on this application is true and complete. FIRM NAME:�J}L Q (� l�� " LIC.NO.:� Licensee: ,pt/iA Signature � ---- LIC.NO.: (If applicable,enter "exempt" n the license number line.) Bus.Tel.No. Address: / a�' L I c�%f-K. S�- # LJ W-1(( Al� ( /� 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 p PERMIT FEE. $��— signature Telephone No. 6�<,_ ❑ 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 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. I ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: I SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ t Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPE TION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Co ents: Inspectors Signature/ Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com I - The Commonwealth of Massachuselts - - Department of IndustrialAccidiints Office of-Westigations 600 Washington.Street Boston,MA 02.111 www.massgovklia Workers'Compensation Insurance Affidavit:Builders/Cont°actors/ElectriexanslPli mbers Applicant Information Please Print Legibly Name(Business/Oxgani'zationllndividual): �i�(0-fel, ;� C�f 4a.Address: City/State/Zip: 0 Lkff 10- Cl l� J Phone#• q'V Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. El I am a general contractor and I 6. El Now constraction f employees(full and/or pait-time)* have hired the sub-contractors 2.14I am.a sole proprietor or partner- listed on the attached sheet 7. El Remodeling ship and'haveno.employees These sub-contractors have 8. E]Demolition worldn for me in an capacity. workers'comp.insurance. 9. g y p ty. ❑Building addition (No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised.their 1011 Electrical repairs or additions 3.El am a homeowner doing all work right of exemption per MGL 11.[]Plumbing repairs or additions myself LEO workers' comp. c.152,§I(4),and we have no 12.❑Roofrepairs insurancere ed. employees.jNo workers' � a 13.0 Other comp.insurance required.] "Any applicantthat cheeks box41 mustalso$Il outthe section below showingtheir workers'compensationpolicy information. Homeowners who submit this affidavit indicatingthey ge doing allworlc and then hire outside contractors must submit anew affidavit indicating such. TContractors that checkthis 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 provicding workers'compensation insurance for my employees Below is thepoliey andlob site information. C Insurance Company Name;_ Policy#or Self-ins.Lic.#: Expiration Date: ,,/ lob Site Address: C�( `e-r `� City/State/Zip: fit/0 le't�j Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). .failure to secure coverage as requiredunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a flue up to$1,50 0.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK.ORDER and a tae 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 AIA for insurance coverage verification. I do hereby cert&under the pains and penalties ofperjury that the information provided above is true and correct. - Si�^ature' Date: Phone#: Official use only. .Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: phone M. .f 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 ofhiw,• express or implied,oral or written." .An employer is defined as"an individual,partnership,association,corporation or other Iegal 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 au individual,partnership,association or other legal entity,employing employees. however the owner of a dwelling house having notmore 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 employes." 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 compliamce with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the r members or partners,are notrequired to carry workers'compensation.insurance. If an LLC or LLP does have employees,apolicyisrequired. Be advised that thisaffidavit maybe submitted tothe 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 andpriated 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 anygiven year,need only submit one affidavit indicating current PORGY 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-lion file for future Hermits or licenses. Anew 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 eta.)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, Y please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho Coxrm0.nweaTthofW_assarhvsP s - Depafteiat ofXildwWaY Acc%denis Office offwestigatjow 600 Washuagton Stxeet BWon,M-A021X1 Tool 617-7-2.7-4.900 eYd 406 ox 1-877-MASS Revised 5-26-05 `ax, 617-727-7749 www.z w• 'govldia I a ' GENERATOR APPLICATION DATE: ! LOCATION: OWNERS NAME: GENERATOR kw 14 KLJ NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: L PHONE NUMBER: � �� ELECTRICAL OAS ' RESIDENTIAL COMMERCIAL TEMPORARY i i LOCATION OF GENERATOR: C--� A,-e- `ZONING DISTRICT: mPLANNING APPROVAL (IF IN WATERSHED) *CONSERVATION APPROVAL,,/144-11 C � $, :.COMMONWEALTH OF MA'S OHLSET"lrS:': I • • ijuslou 4*9 Lou'r-I BOARD Of SSUES. TILE FDL LOWI;::.,>'<>L*1<, Ei ' E 1 .P R `:-"OURNEYMQN ELECTRiI'C! il4 :IwiN FURUSA �•� s _: .... ... ... {{ III ��. J W 127 H'f Er'i4fF S`f SN 11 f.>'<. J `t lkA .011 50-1-8 196 €�, /3i/#� 2735'8 t I Town of North Andover pORTH q o SL80 ti , Building Department 27 Charles Street ti North Andover,Massachusetts 01845 * ,� (978) 688-9545 Fax(978) 688-9542 O <O[ut K1wKK TIED �9SSgcNus���y APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION ADDRESS jl 5 C Lok j1 3 LOT NUMBER 3 SUBDIVISION �l DATE REQUEST FILED DATE READY FOR INSPECTION_-I- I - FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE-INSPECTION FEE OF TWENTY-FIVE($25.)DOLLARS WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. SIGNATURE e!f ,J OFFICIAL USE ONLY ROUTING CONSERVATI �I DATE PLANNING D.P.W. —WATER METER ���lt) DATE ! q (ez( D.P.W. MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIORINSPECTION QUEST DATE. '),/�'?� , ,moo SIGNA / AUTHORIZATION t ............. OF NOR7N'�ti 3�; ao� TOWN OF NORTH ANDOVER o s PERMIT FOR WIRING gs�CHUS� L This certifies thatCA .......... .... ........... .... ......... C'�'.`n.!........ .. has permission to perform �— wiring in the building of...... P..✓1-�.�?�- . .............................................................................. at ......1. .. .. -/1. (P' ...... ... ?.................................`No hAndover,Mass. s Fee... ............Lic. No.� ...G-... ..�I. ............ :.... �!�..... ......:. ELECTRICAL INSPECTOR v Check# ��� • • , 5 T 62paitmE?g ea =1ic-. S2ryces �e�it�eaEw f GARP OF FIRE PREVE-N fOIJ REG ULA i`f ONS Checked I C3ccupazcandea �`a lbig�6 hCil Ap CMOs&450 cfat3'S call a �1Ze lID7j (Iea�e 6�ant� T ``" aitac� C �rrtifAaicar APPLICATION FOR P ERMT TO- PERFORM ELECTRI CAL WORK = wozk fo bapzt'ormed IIC 2CCAICT�IICB BVI l l��'ra$S3¢Tl7JSef[S IeC{11e2j Code(NEC),527 C-MR 12-00 a ; V �'ty t'x i AJ,--D Tk� .jj.�r1r--Op_ -Al C r Tow. �z�. �(c�r�-�, / tlr� To me h7Tecfor^of 0 ims: �3y flus applica-zon tho u-rdem'Zan :.c5 notce obis ortFr,intre Von to pefCrmthe electrical wark described belm �'.oe2faQxc Owner orDaaC�c�',�(4r1Xh1,Cer� 1/S^ �//✓��"r�C.�C•t�T/� �+�a�n� - ' wt: u„ �` (d��ov.. �Yr SC- Tele73Sxan ra 97tf -�oFs6 ~ F3�r°�er's�dtliefi� tisFe p�z)zcnx ailctloa-m*-t..abuiidingpserm�t? yes 1d (filieckAppropra�e�o � VVrp0s0ofRagdtag U.t ui I��trifiorizaf aridoe ws T-ggv%r to fps ! Ir4M5 err ead €indsrd iv'o,a£lipeiers Cie rS`e ce Naps / dolts 0,rvzUa of aers I i70a:o£,L{eBdE?'s and�pacii� . :�oe ta? aax �t=3 e ax?'ropose Electr cal 'oxite t S �\ S<' (� 'ale, S�S�� Compl."et,o�zofzr6';Oi£o-w;tabla7rgheivaiyedbyIlse�rspecforo�Ti!=Y�s 1x .ax 'I'flta8 N"'.-0i P,6,038-aaumi a r g iso.of Ceil.- irT. w ITAramformer-s M •% 'lea:o,�tu`nzn.azr;.Cafl�fs Il o.of mor Tombs' Cerzeraf�rs 7� .above is !,¢=d��zoer�snepk x�.tn -_ kcz.a£kur na?;es ;ri ing ool Me- foo o ecepz cls 3nilefc of OR BMMOTS I1.'ll P ALARM'S of zbnjvel. _�i0.p �LteCtzOZt and `-ero.o,V's.Bmim-ars Tnifsat e�°ices Tota] l'o,az ar�Se i`"ra.o£.Aar co)Ad. �€'ans 'NO.o£Jez�izgDavices 7ta.oa r alta zs asers €of rrinp Nvmbv-r cons ll£W 105.o#Self C©xztarrzerY To Nlls l7eteddozilA ertin�*M3elzcee ur�ici.fra L P11-0-of rtasliers 2ee(txeu: eafin pC � ontac ©rL Eher T? Se cnrrtpS�scese' _ —^ j T��e a€37rS ers eafing pp?Eaxces -a too d e 2c6s dx»qt*ra Vex, eaiers 'z .;ins ^dlasrs lard.o£ se ces or•.9miniTenf sn sI�'eIeclrrdan.�xxrrca�iorrs g�zrizf�s - �(da dronlassa e azc s 1 o.•d,.yFo,ors Td p L�� c£:t)em-ces cz•�gglyf Wi. OTHER- TR as. T.ERT ices si ated aln�45C.Cidcat YUtk 3�� (Whon.regdxedbya-amcipalpolicy.) �s%or�;to Sfam_ �1n.specfions to be recuested in accoMance VV?l l; Ilule YD,a,ad ttpoxl completion. ' �1;;StTCE� �.�.€r�o•T�7lesst�azt-Edb��ihec���e_�no�emorfaz-�IieperForma�.ceofia2eo�'eal�Tor�:xnayxsst�.eruless •:-. .... '�lte sceziseeprov%desproo£ofliabitify insurailc including ucompIcied.ogerao ` cove -6 dz its subsfantal eaui�aIent..1?�e _ nndersigaodsu(,'hcaYzragaisnfQzro,mdbag e-hibifedpxooaof.-5awB to fhe parmit isst&g ofEeQ. -----• C ECK OIT: TT r-9UTIANTC BO'V .� C •l� (Sneourp:) Sel£S�]Surcd �Ce3`itf.}�r zzndex irr�,�airt,2rzd�erz�±tie�afr7e�z�r�*s tXxccf tlz�•Jr�or�nai�ors ole i�7s c�pZcritFoizJ:,r r;�e zrYd eorfzplet� ,i TER,XI rM AT)TftCD)3AD_Tgari diy _� - / 71dCv T ; t�172 Vree lseee l omas �Sz a ye LG �- T"Ta TIITO Q-172 .. 1 c• g1'Q�1�J�3CfS��La el4fer• ,-x'P,Tl2DfnI71sTET•CEI1C8%lTG1�ib�ZY Address, ® �`a�� ��* m 4�®�� y 9� l�?�4 J q ecru,[ty 3sLera€ouu���orzice e,cgztze�roxfhls orkauappIicable,a-aterutelicemailamberh..eT6: QDl7z9 ��>�'�.p�?S+ '�'i'' T�'���V.�l�e Tam.at3�arafiiiattJzeZicenseedoesrzotT.ar'etheliabil��znsuaaicecovera.� nortnalz�' xc fired byfaw. Xy_°D1a;- b:la�,S hara6�t��raTxretis zeguizemenc �am ilxG(ci�er.I�o�e�Q o�x�e� .ozv,�er's menu optarlAggen r.nv.-.enc ..........n.....—• ....w.a.rJ_a w......_w..—...+...w♦ ..._.....w.-.yr •. ucu • � e ....sw .M1 ra.`...Y...n xs .-.-..... ..n..r+.w .. w. ... .... c n .... J I [ f �� Date................................................. OF NORTp,h TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 8`QACMUS� IO This certifies that .......i e 0 R,- . (� ............................................................................... has permission for gas installation .......c,. f ....................... P inthe buildings of. ...... �.1 ...` ............................................................................ at........1.L5)....0 � � C...................... North Andover, Mass. . ................................. 4 Fee...3.(o 1 I . GASINSPECTOR Check# i /t I J -` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY dc}!�� � V ups., - MA DATE 1 15 PERMIT# I11 '5 C- JOBSITE ADDRESS C('%'C' OWNER'S NAME Wop GOWNER ADDRESS _ R v" TEIMAX _j TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL [j RESIDENTIAL PRINT CLEARLY NEW: .-[`f RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES F---Jl NO0 APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER - BOOSTER - ---- - ---- ... CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACES FRYOLATOR FURNACE GENERATOR GRILLE -----._ _._ - --1 -- -- --- - T - r ___ _-_L INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT - .._. � - - C - OVEN POOL HEATER _,- 1 - �J,.__.. _ [� 4111 - ROOM/SPACE HEATER ROOFTOP UNIT TEST* UNIT HEATER UNVENTED ROOM HEATER i h WATER HEATER OTHER INSURANCE COVERAGE - -� have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES J( NO Ej 1 IF`K)U CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND �] OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 01 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. VM; PLUM BER-GASFITTER NAMEy,rv�- ��\�_S LICENSESIGNATURE MP 0 MGF[A JP ®"JGF[:] LPGI 0 CORPORATION©#©PARTNERSHIP El#=LLC[J#= COMPANY NAME:` t.l 4-_ _P wVWI ADDRESS rya _C('✓ -J �r S+__. a,_ CITY w2--���� 1 STATE ZIP TEL - DQq IO FAX .._ _=�I CELL --aa t(p�T MAIL^ l ._ ,` vini►k�'k ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No eS / S� THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES r The Commonwealth of Massachusetts , - - Deparbu nt oflndustriglAccidents Office of Investigations 600 Washington Street .Boston,MA 02111 www.massgov/dia Workers'Compensation Insurance Affidavit:?3uildersfContractors)Electri.ciansffllumbexq Appheant 1'n_formation Please Priunt Leamly Nave(Businessiorganization&dividual): %1 Ikyltl_l VM�0 Address: a Q_(Ac,� Rcd a, City/State/Zip: Wi4. 4 t Y Sy Phone#: 9 s - ad J- to "I/• Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. []New construction f employees(full and/or part-time).* have likedtho sub-contractors 2.1RI-am a sole proprietor or partner listed on the attached sheet.T 7. ❑Remodeling ship and'have no.employees These sub-contractors have 8. []Demolition working for me in.any capacity. workers'comp.insurance. 9, Building addition (No workers' comp.insurance 5. ❑ We are a corporation and its 1011 Electrical repairs or additions required.] officers have exercised.their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.[(Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.QRoofrepairs insurancerequixed.�t employees.(No workexs' 13 J�F er GeN eco�4C Z_- comp.insurance required.] 'Any applicautthat checks box41 must also fill outthe section below showingtheir vforkers'compensationpolicy information. 7 Homeowners who submit this affidavit indicatingthey ke doing allwork and then hire outside contractors must submit anew affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. -ram an employer that is providing workers'compensation insuraneeformy employees Below is thepolley andfob site information. Insurance Company Name% Policy#or Self ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach,a copy ofthe workers'compensation-policy declaration page(showing the policy number and expiration date). Mum to secure eoverage.as requft dunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a fine up to$1,50 0.00 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 Ilereby cert under tiheppains and penalties of per,jury that tree information Provided above is true and correct. - Signature• l�` Date: Phone#• OL) — to r) Official use only. .Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an ernployee 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 redeivex or trustee of individual,partnership,association or other legal entity,employing employees. &o ever the owner of a dwelling house having notmore than three apartments and who resides thereina 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 employes." 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." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes thatapply to your situation and,if Accessary,supply sub-contractors)name(s),address(es)and phone numbers)along with their ceitificate(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 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 if you are required to obtain.a*orkers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their salt-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 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 thatmust submit multi permit/Rcense 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 maybe provided to the applicant as proof that a valid affidavit-ii on file for fiture permits or licenses, Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e.a dog license orliermit 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: Tho Coxrmonw.oalth,ofMassachv.:sP s - D-e-p-aximent Qf Industrid.accidents Qfte QUAvestigationa 6bQ WaMag m Stxoet Boston,MA02111 . �`e�,�f X`����'��4.�QQ e�4q6 ox X-•����-11�A.��.�� _ Revised 5-26-05 Fay,#617-727-7749 Wwwaass,govIdia. I Fold,Then Detach Along All Perforations :COMMONWEALTH OF MASSCHI�SETTS < ,. • • - - • — BQARCT,`O! PLUMBER,S''>AJa' GAS,F;ITTE;RS ISSUES, I�G L THE F L IE:Ns>`b>AS A J 0 U RNE.YMAN-P.Ll7MBt KEVIN P E L L I S 92 CRAWF.DR� 2 fs i�, ���, Lu QwLL IIA 01854-2712':... 11 1 1= €>:''*'<r 3 {:y+.. 05/01/:>? » ` 228253 ...;::.<: is a a Date....�.-�.5 O `7 NOR7M TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,ss/1c MUS - This certifies that .............1J' Sr i �/`.. ..... ........................... ................... ......... has permission to perform ,q� .............. . .................................................... wiring in the building of.........1 U0 ............................................... at... ..�.`?......... !.�. r.... North Andover,Mass. .............. Fee...........- '::.. Lic.No..�3.a.� ........... �. f?..... ........ ELECTRICAL INSPECTAR Check # � 3 7808 Commonwealth of Massachusetts Official Use Only fiz Department of Fire Services Permit No. `7 Y®7- 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 IN INK OR TYPE ALL INFORMATION) Date: // D 7 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersignedgives nnoo�tice of his or her intention to perform the electrical work described below. Location(Street&Number) !/s- c,/�/P��6 . � Owner or Tenant ✓ Telephone No. Owner's Address e--vti es/ Is this permit in conjunction with a buildingpeermit? Yes/M No ❑ (Check Appropriate Box) Purpose of Building �?-cs7x�DcUtility Authorization No. Existing Service o�410 Amps ,�.�O/AO Volts Overhead ❑ Undgrd,o No.of Meters —L New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 4/l2-e Completion of the followin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.-of Ceil.-Susp.(Paddle)Fans o.of Tota Transformers KVA No.of Luminaire Outlets 3 No. of Hot Tubs Generators KVA Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Batter Units No.of Receptacle Outlets 3 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 No. of Alerting Devices Tons g Heat Pum umber Tons KW No.oSelf-Contained No.of Waste Disposers Totals .11. Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local❑ un'cipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.o Water KW No.o No.o Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications firing: 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 cover is in force,and has exhibited proof of same to,,t�e permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) Z t/S o /r� _1 I certify,under the airs and penalties o perjury,that the information on this application H true and complete. FIRM NAME: % o�t'G i�,_- _.mow(!- LIC. NO.: / O Licensee: 1-*4m /7,-' Signature IC. NO.:1�3W7f (If applicable, enter "exempt"in the licens number line. Bus.Tel. No. Address: �1 c9�'��i/ I JAG �. ems✓ ��,(�i�,�r Ito o4e7e Alt.Tel. No.: ;.f' � *Per M.G.L c. 147,s. 57-61, security work requires Department of Public Safety "S" License: Lic.No. OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, 1 hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $