Loading...
HomeMy WebLinkAboutMiscellaneous - 120 WATER STREET 4/30/2018 (11)Date ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .................. .. QXv ... ...... has permission to perform ........... F .. f7?i .................................................... ..................... wiring in the building -or ........... ....... ...... ................ ..... ... ... .. . rt r at .... . ......................................... N9 0 -h Andover, Mass. 0 Fee .Lic. No. ..... . ................. .... ......... ...................................... . ............. . . ....... ELEmRkAl, INSPECTOR Check.# 1 nly Commonwealth ®f Massachusetts Official U//see `O/ Department of Fire Services Permit No. Occupancy and Fee Checked 1''\ BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (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 HK OR TYPE ALL INFORMATIOA9 Date: l� City or Town of. NORTH ANDOVER To the Inspectorof Wires: t, By this application the undersigned gives notic'e/ of his Qr her intention to perform thq electriccaall}wr�o kescri/beed below. _ Location (Street & Number) wner or TenantTelephone No Owner's Address 1,7 7 Is this permit in conjunction with a building permit? Yes F1 No ❑ (Check Appropriate Box) Purpose of Building ��% "d11#11- Utility Authorization No. - Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ pi. U d( rd No. of Meters on r. Completion of the following table maybe waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: 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 Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches 7 No. of GB Gas No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers p Heat Pump Totals: Number Tons KW .......................Detection/Alerting No. of Self -Contained Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other 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. 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:%D (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 e is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE V BOND ❑ OTHER ❑ (Specify:) X certify, under the pains and enalties of erju that the i f oration=tZlIcation' is true and complete. FIRM NAME:. 1�� , LIC. NO.: Licensee: VZIIW6119 Signature LIC. NO.: (If applicable, enteA xempt" int f linse�u er 1' Bus. Tel. No.• Address: ��f'!% �C G� Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department offxblic 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 PERPvlIT FELE: $ Signature Telephone No. f ❑ 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 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 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass R Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ' ROUGH PECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Com nts Inspectors Signature: Date: FINAL INSP ON: Pass ? Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: �� 4✓S Z % Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: ��V /l/ Z- IQ/ 0& City/State/Zip: Phone #: ��� *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. 1Contractors 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: / �/� ��� �/ r" City/State/Zip: A l�/�U�������/ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expirati date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a f9 e 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. Ido hereby certify under tl pains a d penalties of perjury that the information provided above is true and correct. 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 6. Other - Contact Person 4. Electrical Inspector 5. Plumbing Inspector Phone #: Are y an employer? Check the appropriate box: Type of project (required): 1. Ei am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # E] 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 10.❑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.❑ Roof repairs 4 insurance required.] t employees. [No workers' 131:1 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 a new affidavit indicating such. 1Contractors 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: / �/� ��� �/ r" City/State/Zip: A l�/�U�������/ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expirati date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a f9 e 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. Ido hereby certify under tl pains a d penalties of perjury that the information provided above is true and correct. 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 6. Other - Contact Person 4. Electrical Inspector 5. Plumbing Inspector Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application 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 bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth ofMassaclzusPtts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston., MA, 02111 Tel, # 617-727-4900 oxt 406 or 1.-877rMASSAFB Revised 5-26-05 Fax # 617-727-7749 www.mass,govfdia a Date .... ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .............. ..................... .............................. has permission to perform 7 wiring in the building of... .................................................... .......................... . .................... or ..... at ....... 1.2,0.. X ..... --"r .................. .. North Andover, ass. Fee.. U?�� Lic. No. ):A -M ............. . .. . .. . . ...... LE** c*'r'R**I'C* A PO L*INSPE R Check # 1 07 87 The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations to 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: 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).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a.homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ 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. $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: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required. under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: 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 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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFB _ Revised 5-26-05 Fax # 617-727-7749 www.mass.govldia A Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. _ 7 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (AMC), 527 CMR 12.00 (PLEASE PRINT W NK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his r her 'intention to perform the electrical work described below. Location (Street & Number) /Z-0 Ie �j-/,�; X11 , Owner or Tenant C—t, - Owner's Address /? 141#4029 Telephone No. Is this permit in conjunction with a building permit? Yes Purpose of Building �il'/fJ-L +`' NO EJ (Check Appropriate Box) Utility Authorization No. Existing Service 'Amps / _Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead Number of Feeders and Ampacity EJ Undgrd ❑ No. of Meters Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers No. of Water KW o. Hydromassage Bathtubs OTHER: 162 Of Ceil: Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Above ❑ �rnd No. of Oil Burners No. of Gas Burners vo. of Air Cond. To Area Heating KW g Appliances KW No. of ;ns Ballasts No. of Motors Total HP 70 he o. Generators KVA IRE ALARMS I No. of Zones o. of Detection and ` Initiating, Devices o. of Alerting Devices X Wiring: ❑ 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: INSURANCE ❑ BOND ❑ OTHER I certify, under the ains an ❑ (Specify:) P / �p�enalti �ofperjury, hat the inf tion on this application is true and complete FIRM NAME:/ (+- Licensee: /U LIC. NO. (� Signature , (Ifapplicahle, enter `exemp " int a lic nse nu her li LIC. NO.: / Address: Z` �Y� / /D� Bus. Tel. No.• 0 *Per M.G.L c. 147, s. 57-61, security work requires Department o ublic Safety "S" License: Alt. Lee. 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: S ELECTRIM PEPMT NO. WSPECUO REPORT. E�ECT�1fCAL 3[N'SPEC�'®� •-. _ , CTION, , Passer— Re-iuspeciaon xequiurecX($50.00) - [ I Inspectors' comzneJnfs: n�pec oxs' Si tore o initials) Date D. • mYR GUOUND MPAMON. Passed -- [ I FaUed — [ I Re -inspection required ($50.00) - [ I Inspectors' comments: (inspectors' Signatare •- no initials) Date DOOR TAGS .AR -^ TO BE FREED OUT AND LEI'T ON RITE IF THE APXA. TO BE INSPECTED 18 NOT ACCESSIBLE AND ARE WSPECTION OP' $50.00 I8 TOM CHARGED. Passedt, Failed—[ I Re-inspecti.onrequired ($50.00) •- [ j xnspect S mments: �3 y (Czispectors' Signa no inzr Ts) Date D. • mYR GUOUND MPAMON. Passed -- [ I FaUed — [ I Re -inspection required ($50.00) - [ I Inspectors' comments: (inspectors' Signatare •- no initials) Date DOOR TAGS .AR -^ TO BE FREED OUT AND LEI'T ON RITE IF THE APXA. TO BE INSPECTED 18 NOT ACCESSIBLE AND ARE WSPECTION OP' $50.00 I8 TOM CHARGED. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... %G.......L.............. has permission to perform .�M L 4y�r� ..... Ve, ...... ... .. .............. ..... ... .................. wiring in the building of .... �4 .......... Andover Mass. r JFee../ ............ Lic. No. /V/ ............. . 4i'ZIEAL' NSPE -Check # (/ 10754 Commonwealth of Massachusetts Official Use Only 7 Department of Fire Services Permit No. -76 Occupancy and Fee Checked y 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: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention toperfo the electrical work described below. ` � Location (Street & Number) Jc Owner or Tenant's ZLc Telephone No. Owner's Address IDO a,6 Is this permit in conjunction with a building permit? Yes :9 No ❑ (Check Appropriate Box) Purpose of Building aq a JI&W Utility Authorization No. Existing Service Ams / Volts Overhead ❑ Und rd El No. of Meters P g New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: /—o Completion of the following table may be waived by the Inspector of 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 AboveIn- Swimming Pool rnd. ❑ rnd. El o. 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. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pum Number . Tons KW I ....................... No. of Self -Contained Totals F Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Z'0 Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent ZId OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: � O (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 0' BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the informatio is lication is true and complete. FIRM NAME: //� T�-( /,G���/ % i l/ (L /. / LIC. NO.: Licensee: 17k .r� Signature �� �l�r/� LIC. NO.: (If applicable, enter " xem t" in he license um r line) n div' / Bus. Tel. NO.: Address: /4i 71�/�i�/DL%,/�y[/v %f%�%�/� 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 Signature Telephone No. PERMIT FEE. $ ClIvIt/��� � �279 -,z?l -INO Jk (f 6111060b� e- Alri�5Z&- /,,0//0/ AJCI�OVC'. Z�10; ACORD TM. CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 04/03/2012 PRODUCER Phone: (978) 475-0400 Fax: (978) 475-2171 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION THE HOWE INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 4 PUNCHARD AVE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ANDOVER MA 01810 ALTER THE COVERAGE AFFORDED BY THE IFS RELOW. GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE [X] OCCUR OHN9310175 08/17/11 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Hanover Insurance Co PERSONAL & ADV INJURY $ 1,000,000 INSURER B: A I M Mutual Insurance Company GENERAL AGGREGATE $ 2,000,000 INTELLIPHONE INC 191 CHANDLER ROAD MA 01810 INSURER C: INSURER D: AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS INSURER E: ,ANDOVER COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADD'L INSRO TYPEOF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM/DDfM POLICY EXPIRATION DATE MM/DD/YY LIMITS A JURnstine J. range GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE [X] OCCUR OHN9310175 08/17/11 08/17/12 EACH OCCURRENCE $ 1,000,000 _ DAMAGE TO RENTED $ 300,000 PREMISES (Ea occurence) MED. EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: - POLICY JPROECT LOC PRODUCTS-COMP/OPAGG. $ 2,000,000 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY Per person) $ ( BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS / UMBRELLA LIABILITY OCCUR El CLAIMS MADE DEDUCTIBLE RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below WC7024772012011 08130/11 08/30/12 ATU-LIMIT OTHER TORY TORY LIMITS E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE -EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 OTHER: DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER NORTH ANDOVER MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, IT'S AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Attention: JURnstine J. range ACORD 25 (2001/08) Certificate # 8709 © ACORD CORPORATION 1988 9361 Date . �'<«•� 4 TOWN OF NORTH ANDOVER ice —0 * PERMIT FOR PLUMBING S' 'SSACNUSE� �`� This certifies that ... 7,�� . ! ...e`��� `�✓ ,� til �' .... has permission to perform plumbing in the buildings of....�� .................. at ... fZG %,v ' f `-Sr .... , rt A oyer, Mass. f/ PLUMBING INSPECTOR Check # 7 �6 &'M / a -z-- - TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY North Andover MA DATE April 2, 2012 j PERMIT # JOBSITE ADDRESS met / (�j�% 1 OWNER'S NAME RCG LLC OWNER ADDRESS 121 Ivaloo Street Somerville, Ma TEL 61725-8315 FAX OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL NEW: El RENOVATION:E] REPLACEMENT: ® PLANS SUBMITTED: YES ® NOE] FIXTURES T FLOOR— BSM 1 2 3 4 5 6 8 9 10 11 12 13 14 BATHTUB r7 CROSS CONNECTION DEVICE ®� DEDICATED SPECIAL WASTE SYSTEM, DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK 1 LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK�� TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES�� WATER PIPING OTHER 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 CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ® BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNEREI 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. �`— PLUMBER'S NAME I James Greene LICENSE # 15152 ) SIGNATURE MPEI JP® CORPORATION®#PARTNERSHIP®#.LLC ®# COMPANY NAME I J.P Greene P & H ADDRESS 174 Bridge Street CITY I Salem ISTATE NH ZIP 03079 TEL 603-893 8525 FAXI CELL 978-423-7694 EMAIL j2mgree33@comcastnet -.1 .The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leibly Name (Business/Organizafion/Individual): S �1 MP �'£AJ / Address: 2 R-Id9 e City/State/Zip: _ S 4 % e A�4 , �/ N �j 3A Phone #: (G 0 3) 9 3 - Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. W I am a sole proprietor or partner- / I listed on the attached sheet. T ship and have no employees These sub=contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5• ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] my Pnnliran-thct nhF Ln t..,t- a 1 Type of project (required): 6. X New construction 7. ❑ Remodeling 8. .0 Demolition 9. ❑ Building addition 10. F-1 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other • �ao:� Wb r^. �� wa•��;• coY:;,�•Satson po?iCy inforn.�fioa. 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: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do hereby ce and pains and penalties of perjury that the information provided above is true and correct 7h 2' 3-7G91-/ Offcial 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 6. Other Contact Person: CiVTown Clerk 4. Electrical Inspector 5. PIumbing Inspector 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 coinpliance 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 cerdficate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with.no employees other than the members or partners,. are not required to carry workers' compensation insurance. If an LLC or.LLP does have employees, a policy is required Be -advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation^ of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the aU hicat-•ion for hepermit-r ice ebeingrequest--d t f f '`y � o, license is , no the D r artmen.. 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 permitilicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business. or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 uw.mass..govfdia Date . Vj-//C, 1 4k 1 � NORM TOWN OF NORTH ANDOVER 'le pL PERMIT FOR PLUMBING This certifies that ....�.d' <V.e: !....(r-.6:: �................... . has permission to perform .... . j ........................... . plumbing in the buildings of ... l� �. G ..: �. �. C ................ . at .... %.l.. u ... J. (............ , North Andover, Mass. Fee.. TP ...Lic. No.. / : ....... PLUMBING INSCTOR Check # 8557 CN- MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING r City/Town: IV b /'f kP A NdOy e g MA. Date: V /7 h6 Permit# Building Location: /aa W/afe2 Sf Owners Name: /�7 e Type of Occupancy: Commercial [V Educational ❑ Industrial ❑ Institutional ❑ Residential ❑ New: ® Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES INSURANCE COVERAGE: I have a current liability -insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes M No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy M Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's 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. By Type of License: l Title Plumber Signatu f Licensed Plumber Ci /Town Master APPROVED OFFICE USE ONLY) ❑Journeyman License Number: 5 /5 DEDICATED SYSTEMS LU z z Z ` v O W to d y CC Z z a H Y Z Q V Q N Z W D 2 Q H W LU LU Z Q$A ca W X 1A K CAV1 CC Z ~ V) W Q Y a ~ Q Y= = d 0 3 Z O Q W a �0 3 a W Y Z i-" Lu W tA WIA °x u v=i tW- a m m o o� >: g s o°c ►Q- 3 3 3 o a c� 43 3 ' SUB BSMT. BASEMENT ' 1ST FLOOR 2ND FLOOR 3RD FLOOR 4YH FLOOR 5m FLOOR 6m FLOOR FLOOR 8TH FLOOR Check One Only Certificate # _ Installing Company Name: J ,A M RS' 6 re c N, p� ❑Corporation t Address: V dr City/Town: SA /e Nt State: N ❑ Partnership Business Tel: (?76 J '/-a3-79 i V Fax: Firmicompany Name of Licensed Plumber: ,M GY'e e ni INSURANCE COVERAGE: I have a current liability -insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes M No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy M Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's 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. By Type of License: l Title Plumber Signatu f Licensed Plumber Ci /Town Master APPROVED OFFICE USE ONLY) ❑Journeyman License Number: 5 /5 Date.... v'/.,.. . TOWN OF NORTH/ANDOVER dr •` oc 1 ' PERMIT FORYLUMBING This certifies that .. •. ... r L.... r .... ... ............. . has permission to perform ...... �A' I .......... plumbing in the buildings of .................................. at ... ,/. l..e�....Y-!. 0. . �. ° .. ` �........ I North Andover, Mass. Fee .. Lic. No... ? . �� . ........�,!1...... . PLUMBING INSPE TOR Check # `� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING ' City/Town: AJt"r+'-N ANO0v#.t2 MA. Date: N Permit# Building Location: ) a -O W A T F. Y St . Owners Name: C L' 10w Zr r,4 v p Type of Occupancy: Commercial X Educational ❑ Industrial ❑ Institutional ❑ Residential ❑ DEDICATED New: Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES 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 indicate the type of coverage by checking the appropriate box below. A liability insurance policy ® Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner E] Agent El 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. By Type of License: Title ® Plumber Sign re of Licensed Plumber City/Town_ ® Master License Number: ��%� APPROVED OFFICE USE ONLY)[:]Journeyman DEDICATED SYSTEMS z z z W H 4A Q a z ,n 4A a �, } z_ F x ,� u �+ �oQc Z o 0 Z h z O m W iz9 LU z_ W y W F- N O Z u inLJ6 D a 1� x J W Fj a O 4A LU 0 C 3 R z 3 LU Lu z W cid O LU 3 n0. u z v7 t o o E>> 0 a o= o U vxi Q a a Uj a G u a vii o a a m m c c� x x g g ae .n vA 1 3 3 3 0 a l7 0 3 SPJB BSMT. 9ASEMENT 1sT FLOOR 2ND FLOOR 3RD FLOOR C FLOOR 5m FLOOR 6m FLOOR r FLOOR r FLOOR Check One Only Certificate # Installing Company Name: JAMe.S ��t2F� N�_ p -f#4 El Corporation Address: 7 y r l Lde 1 City/Town: SA 1 e lt, State: Al A/ E] Partnership Q Business Tel: / 7% " V� 3 76 � ' Fax: ❑ Firm/Company Name of Licensed Plumber: rec tv e-- 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 indicate the type of coverage by checking the appropriate box below. A liability insurance policy ® Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner E] Agent El 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. By Type of License: Title ® Plumber Sign re of Licensed Plumber City/Town_ ® Master License Number: ��%� APPROVED OFFICE USE ONLY)[:]Journeyman Date ....I/...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .................... ... Alovi �� ...................... ............ j ...... has permission to perform .......... — wiring in the building of ............. ...cl......................................................... at ....... ...... 52 .................. North Andover, Mass. T -?9 FeeJ .2...... -5 — .......... Lic. No. ....... 711a....... .. ..... . .... . ... ....... ELECTRICAL NS R Check # 9318 2L_\ Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only�q Permit No. C� Occupancy and Fee Checked tev. 1/07] n— 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 W AW OR TYPE ALL XFORALMOII9 Date: City or Town of: NORTH ANDOVER By this application the undersigned gives notice of is or er in ention to perform the To the Inspector work f Wires: below. Location (Street &Number) �,0 �/�i� Owner or Tenant ®li Owner's Address Is this permit in conjunction with a building permit? Yes`j Purpose of Building �o In /ham, J,I A-(., No ❑ Existing Service Amps Utility Authorization No. Lew Service / Volts Overhead ❑ Undgrd ❑ Ne _ Amps / _Volts Overhead ❑ Undgrd" ❑ Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: phone No.t11_!, t -v, " --------------- No. of Meters No. of Meters (Check Appropriate Box) No, of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires — . No. of Receptacle Outlets Mers ches ges te Disposers washers rs eraters KW No. Hydromassage Bathtubs corn letion of the No. of CeiL=Susp; (Paddle) Fans No. of Hot Tubs Swimming PoolAbove ❑ In- nd. gn No. of oil Burners 5 INo. of Gas Burners No. of Air Cond. Total ns eat ump Number Ons s l Totals: No. of Tunes - Space/Area Heating KW Heating APPhances KW No. of No.7 of Si s Ballasts . No. of Motors Total HP win table m be waived by the Inspector of Wires. 0.0 Total . Transformers KVA Generators KVA 17 o. o mergency T g L_jBatte Units / " E ALARMS No. of Tunes o. of Detection and Initiafm Devices No. of Alerting Devices o. of elf -Contained Detection/Ale Devices Local ❑ Municipal Connection Other Security Systems; No. of Devices or E uivalent Data Wiring: No. Devices of or E uivalent TelWiring: No. of Devices or Eauivalent Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. Work to StartIn(When required by municipal policy.) spections 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 incnrance including "epmple�d operation" coverage or its substantial equivalent The CHECK ONE: INSURANCE BOND ❑ OTHER undersigned certifies that such coverage is in force, and has exhibitedted proof of same to the permit is office. FIRM NAME: n OG( I certify, under the pains anal B afP�1ury, that th❑.(Specify:) , e inf adon on this application is true and complete. �/ Licensee:Signature LIC. NO.: ©� (If applicable, enter " pt " in t li enaenu nther 'ne.) LIC. NO.: Address: as. Tel. No.: *Per M.G. c. I47, s. 57-61, security work requires Department of Public Safety "S" License: LicAIL Tel 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/Aent Signature" Telephone No. PER1f�IT FEE: ,�' R - f e1c t9� '14 41- j 4 The Commotrwea&k of Massachusetts k j Department of Industrial Accidents ' Office of Investigations ; M 4/ j 600 Nlashingion Street •�� _�. Boston, MA 192.111 www nassgov/dia Applicant . Workers' Compensation Insurance Affidavit: Builders/Contra.ctorsMieciriciaas/Plambers Iaform.2tion Pie se Print Ledbl Name (Business/Organization/individual): Address: 'A/Q P—: City/State/Zip:�.�,� Phone #:. �v�7 FA employer? Cheek.the appropriate bDX: a em to er with Type of protect ( �;P y 4. ❑ I am a general coj or and I intyees (full and/or part-time).* have hired the sutractors 6. ❑ New construction .so}e proprietor or p>i�_ listed on the attacheet t 7• ❑ Remodeling nd have no employees 'These sub-contrahaveng for me in an ty 8. ❑ Demolition y capaci workers' camp. ice.orkers' comp. insurance 5. ❑ We are a corponid its 9 Building addition ed jofficers have exertheir 10.0 E}ecttical.a homeowner doing all work right of exemptioGL I I.�] Plumbin �� or rgyself. [No•workers' comp._ c, 152, § I(4), and ve no grePau'soradditions insurance requiretL] t em 1 12. ❑ Roof r -pairs p ogees. [No ws'comp• insuratrtx.:rcL] 13.0 Other "/+ny applicant that checkssubmit boil # t must also fill out the section below showing theirworked' co t homeowners who submit this affidavit indicating they are doingall work mpensa#ion policy in formation, 4conttnctors that check this box musranaahed an additional shextsho end than hire outside cvnteactoia must submit a new affidavit indit�tiag wing the m me of the sub-cortrftctrns.� a W s i suclL am an employer that is ro ' :.::- rip. poliiy iniamatioa. io , wdtng:warkets compensation insuraneefortzry. e inforrnaiion. ArloyeaL Below is the policy andjoh site Insurance Company Name: ' Policy 4 or Self -ins. Lic. #: Expiration Date: Job Site Address: City/state— /zip-Attach a copy of the workers' 'eoutpeusabon policy declaration page (showing the policy Failure to secure number and e:tpiratioa date coverage as required under• Section 25A of MGL c. 152 can lead to the imposition of criminala fine up to $1,500.00 and/or one-year imprisonment, as well tis civil penalties in the fonn of a STOP WORK ORDER and a fine of up to 5250.00 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 Un er the p ' is and p a 4fperlWy that the information provided above is true and eorre 7 ct Date: 7 A, Off"cial use nay. Do not write in this area, to he completed by .chy or town— City or Town Permit/License # Issuing Authority (circle one): I. Board of Health 2. Soilding Department 3. City/Town Clerk 4. Electrical Inspector 5. Pin 6. Other g Inspector Contact Person: Phone#: p /�►J�.i ti li / `-e' // .rte Location r No. c�� Dated M NoRTh TOWN OF NORTH ANDOVER a 0 09 Certificate of Occupancy $ �as�CMusE<� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 0 i 22727 Building Inspector `_ . anvil h ♦T� �i ZSSS+. 8�ClplO CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 200 (9/14/09) Date: December 2. 2009 THIS CERTIFIES THAT THE BUILDING LOCATED ON 120 Water Street MAY BE OCCUPIED AS Tenant Fit Un — ERS Bldg 11, 2nd floor IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: ERS 120 Water Street Bldg 11, 2nd Floor North Andover MA 01845 J* �J .l' J Building Inspector I BUU1�t-T9 HILL December 2, 2009 Mr. Gerald Brown Inspector of Buildings Town of North Andover 1600 Osgood Street North Andover, MA 01845 Re: ERS Tenant Fit -Out Building 11, Second Floor East Mills, North Andover Burt Hill Project 07804.14 Dear Mr. Brown: The tenant improvements for ERS on the second floor of Building Eleven, at East Mills in North Andover, MA, were to the best of my knowledge, belief, and understanding, constructed in conformance with the construction documents issued for building permit dated September 14, 2009, Permit #200 in accordance with 780 CMR Commonwealth of Massachusetts building code. During the course of construction, representatives of our office made periodic visits to the site to observe the progress of the work. Sincerely, BURT HILL Linda S. Smiley, AIA Senior Associate Phone: 617.654.6003 cc: Kieran Whelan David Steinbergh Architecture Engineering Interior Design Landscape Master Planning 303 Congress Street 6th Floor Boston MA 02210- 1012 tel: 617.423.4252 fax: 617.423.4333 www.burthill.com ,;�J El Permit Affidavit Project Number: ENERGY RESOURCE SOLUTION Project Title: ENERGY RESOURCE SOLUTION — EAST MILL Project Location: East Mill North Andover Name of Building: 120 Water Street, North Andover Nature of Project: Commercial Tenant Fitout In accordance with section 116.0 of the Massachusetts State Building Code, I Alfred M. Marzullo Registration No. w- eing a Registered Professional Engineer/Architect hereby certify that I will prepare or directly supervise the preparation of all design plans, computations and specifications concerning: Entire Project Fire Protection X .HVAC—X, Electrical PlumbingX_ X Other(Specify) For the above named project and that, to the best of my knowledge, such plans computations and specifications meet the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and applicable laws and ordinances for the proposed use and occupancy.. I further certify that I shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the documents approved for the building permit and shall be responsible for the following as specified in section 116.2.2: 1. Review of shop drawings, samples and other submittals of the contractor as required by the construction- contract documents as submitted for building permit, and approval for conformance to the design concept. 2. Review and approval of the quality control procedures for all code required controlled materials. 3. Special architectural or engineering professional inspection of critical construction components requiring controlled materials or construction specified in the accepted engineering practice standard listed in Appendix B. Pursuant to section 116.2,3 1 shall submit periodically, a progress report together with pertinent comments to the _North Andover Building Inspector. Upon completion of the work, I sh2s:Ff P44nal report as to the satisfactory completion and readiness of the project for occupanc` LLU Signature and Stamp 1/4/10 Date On thisday of SA1�l Q.�. 20 l UUU me, the undersigned notary public, personally appearedkXCC, M. M NeZo (name of document signer), proved to me through satisfactory evidence of identification, which were WM&) -\ip rAr-" g& the person whose name is signed on the preceding cr,attached document, and acknowledged to me that he/she signed it voluntarily for its' stated pjarpose. My commission expires NOTAR P LI Sara. E. Addieg Notary -Public Coff=nwealtt of mossochusetis My Commission Expires October 27, 2011 Date....�.....Y �.�. TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that ....... has permission to perform..... .....................:.. P wiring in the building of '��� . ' ' L r'! `. ......��,: at.................................................... `................orth Andover, ass. Fee) ZS . Lic. NoZ" 7�' ..................l.�,t'' ........ r�f .. �..... EE" ° .-�..... LECMICAL INSPECT'OR Check # r °r. e - a - .. t F i:. r` zopaftownt VON BOARD OF FIRE PREVENT I ION REGULATIONS Official LZse /Only Permit No. / Occupancy and Fee Checked [Rev. 1/071 eave blank APPLICATION TI FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perfortrned in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 1100 (LEASE PRINT IN INK OR TYPE ALL INFOR.141A17 1A9 Date: zz_zz, pity or Tawn of: ND/zT7;� �,!>lryff" /� To the Ins eetor of xftres. By this application the undersigned gives notice of his or her intention to -perform the electrical work described below. Location (Street &. Number) 1 g ) �S=, �E Owner'or Tenant OLvviU� 1S' Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No (Check Appropriate Box) Purpose of Building Utility Authorization No, (Existing Service Amps t 'Volts Overhead ❑ Undgrd ❑ No. of Meters' New_Service Amps / Volts Overhead ❑ Und rd g E] No, of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: rjx 641 , No. of Recessed Luminaires No. of Celt, -Susi. (Paddle) Pans o. o Tota Transformers KVA No, of Luminaire Outlets No. of Hot "rubs Generators K'VA No. of Luminaires Swimming Pool Above n- rud. grud.. o, o Emergency g €tg Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No, of Gas Burners o4 of n Initiating Devices No. of Ranges Total No..of Air Cond. Tons No. of Alerting Devices No, of Waste Disposers eat Pump ' usn er Totals: I Cnns o. of SeI - ante ne Detection/Alerting Devices No. of 'Dishwashers Space/Area heating KW Local[]municipal 0 OtherConnection No. of Dryers Heating Appliances; KW SecuritySystems-* No. of Devices or Equivalent No. 4 alar K 4'`' Heaters o, o o. o Signs Ballasts Data Wiring: No, of Devices or Equivalent No. Hydromassage Bathtubs N9;*f Motors Total HP c ecommun cations Wiring; No. of Devices or E uivalent OTHER. Attach additional detail ildesired, or as requited by the inspector of Ares. Estimated Value of °Iectr cal Work: *6000 , OD (When required by municipal policy.) Work to Start: 2 Inspections to be requested in accordance with MEC Rule iii, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work tray 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 cerrtafy, under the pains aced peraallks of perjury, that the Information, on bias apptscaden is twee and complerc FIRM NAME: ` b/V,4 vAl LIC. NO,: 71"<f_ Licensee; ` e e , Signature LIC, NO,: (tfapplicable, enter ••exempf" in the license prMberline.) Bus. Tel, No.• T .� Address; !4_ _t: TL S s/. D�C3&=4�4 2-ZY° Alt. Tel. No:; 33'7:2�L2 /I *Per M.G.L. c. 147, s,'57-6 1, security work requires Department of Public Safety "S" License: Lic; No. 00/ OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage norma required by law: By my signature bellow, I hereby waive this requirement. I am the (cheek one Q owner owner's agent. Owner/Agent Signature Telephone No, Pei t $ �� Q� 0 Date/'" Of tHORr 4,. TOWN OF NORTH ANDOVER/ PERMIT FOR PLUMBIN This certifies that has permission to perform ... /T. .......... plumbing in the buildings of .... ......F«.: P..-�-... at. . /�.6— ............... North Andover, Mass. Fee. No.4).-0.-.? . ...... 11 �'L 1''GINSPECTOR ' * Check # 3e 3 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING - j (Type or print) NORTH ANDOVER, MASSACHUSETTS %� -// +'t Date ®I % Building Location �f Owners Name QPC � o ,�,( '[� Permit # 'p— Amount Amount ` l U1 Type of Occupancy M M e - r e i, A l New Renovation �( Replacement Plans Submitted Yes ❑ No ❑ (Print or type) Check one: Certificate Installing Company Name eQ /,7G �12 f� �1 �'y/I ® Corp. Address �/ V � L 7, Partner. fti mess Teleph ne (. 7Sti Gi° a 3 - -7Z 9 Y ® Firm/Co. Name of Licensed Plumber: ��/� L 6 /21 Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity13Bond ❑ Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac setts State P ng Code and Cha ter 142 of the General Laws. By:SignaEUF 01 LAcenseaum er Title We of Plumbing License D 6 , �, City/Town 1CenSe um er Master APPROVED (oMcE USE o[%j Journeyman ❑ONLYj�J i =MM .. �ri�®nnnnn�MnnMM nM n®nOnnn� IF .. MMMnnnnOn��n�n�������sn�n� .. MMMMMMMMM���wvnnan�n�asnnno (Print or type) Check one: Certificate Installing Company Name eQ /,7G �12 f� �1 �'y/I ® Corp. Address �/ V � L 7, Partner. fti mess Teleph ne (. 7Sti Gi° a 3 - -7Z 9 Y ® Firm/Co. Name of Licensed Plumber: ��/� L 6 /21 Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity13Bond ❑ Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac setts State P ng Code and Cha ter 142 of the General Laws. By:SignaEUF 01 LAcenseaum er Title We of Plumbing License D 6 , �, City/Town 1CenSe um er Master APPROVED (oMcE USE o[%j Journeyman ❑ONLYj�J Policy #. or Self -ins. Lic. #: Expiration Date: Job Site Address:_ Attach City/Stateizip: ti copy of the workers'. compeusation policy declaration page Failure to s(showiag the policy cumber and expiration date]. ecure coverage as required under Section 25A of MGL C. 152 can lead to the i fine up to $1,500M and/or one-year imposition of criminal mprisonment, as well tis civil penalties in the form of a STOP WORK QRpenaltis of a, DER and a fine Of up to $250.00 a day against the violator. Be advised that a copy Investigations of the DIA foof this statement may be forwarded to the Office of r insurance coverage verification. I do hereby cer*� under the lad pear/ties of perjtoy that the inforn"on provided above is tate and correct, --- Date: 0 f Pho nei j se aniy. Do not write in this area, by be completed or town ol'Ycity ficial own Permii/Licenseatiroriiy (cirdt ole): of Health 2- Suiiding Department 3. City/Town Cierk 4. Electrical Inspector 5.Plumbing inspector erson: "" Phone#: The Commonwealth of Massachusetts 'F kj r� or ! Department of Industrhd Accidents Office Investigations: �' of °��` 600 Af ashinvion Street ti Boston, MA p2111 c wwrv_mas&gov/dia . Workers' Compensation Insiurance Affidavit~ Builders/Contractors/Electriciaas�pfambe A 3icant Imfora�ation rs Please Print La 'bl Name (Business organization/Individcial ): AMzS �►�i�N Address. City/State/Zip: Phone At. FAEriyou an employer? Cheelttbe appropriate box: fect (required): I am a employer with 4. ❑ I am a general contractor and IF7O employees (full and/arpOrt-time).* .a.sole proprietor or have Iatred the suis-cantracors constructionlam listed partner- ship and have no employees on the attached sheet. I ocw-. g These sub•.contractors have working for me in any capacity. [Tho workers' comp. insurasice workers' comp. insurance. olition 5. ❑ We are a corporation and its I.ing addition required_] I am ahomeowner doing officers have exercised their ical repay oraddiiions3.❑ all work myself [No -workers' comp. right of exemption per MCL bing repairs or addititms c, t52, § I(4), and we have no insurance required.] t ernployees. [No workers' 12 Q Roof repairs 'cDmP. %nsumncb required.] 13 -EI -Other My e{tplita;rrt tient Checks boat # I must also fail out the section below showing their workers' compensation Policy information 1 Fiomeownera who submit this affiliavit indicating they are tiling all work and than ham outside eontnmetm mu8t'submit a new affidavit in(licating such ;Contractors that Chcgk this box raustattaohal an atkd,•tiaasl shear ahow' aEg the name of the sub-cannactors and their workers' ce �ti �. am an earPlosyer firm ="7- �:woFicers' cor�rPe�m►*+n inswaace or ` in£onnadon. inforrnatian f �' employees: Below is the pog,:�> mid job site . Insurance Company Name: ' Policy #. or Self -ins. Lic. #: Expiration Date: Job Site Address:_ Attach City/Stateizip: ti copy of the workers'. compeusation policy declaration page Failure to s(showiag the policy cumber and expiration date]. ecure coverage as required under Section 25A of MGL C. 152 can lead to the i fine up to $1,500M and/or one-year imposition of criminal mprisonment, as well tis civil penalties in the form of a STOP WORK QRpenaltis of a, DER and a fine Of up to $250.00 a day against the violator. Be advised that a copy Investigations of the DIA foof this statement may be forwarded to the Office of r insurance coverage verification. I do hereby cer*� under the lad pear/ties of perjtoy that the inforn"on provided above is tate and correct, --- Date: 0 f Pho nei j se aniy. Do not write in this area, by be completed or town ol'Ycity ficial own Permii/Licenseatiroriiy (cirdt ole): of Health 2- Suiiding Department 3. City/Town Cierk 4. Electrical Inspector 5.Plumbing inspector erson: "" Phone#: i Information a nd Instructions' Massachusetts General Laws chapter 152 requires all emp Ioyers 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, mc:idiation, corporation or other legal entity, or any two ormore of the'fomping engaged in a joint enterprise, and includirig the legal representatives of a deceased employer, or the receiver or trustrz- -of an individual, partnership, associatioin or other legal entity, employing employees. 'However the owner -of a dwelling house having not more than three apaxl=cnts and who resides therein, or the occupant of the dwelling house of another who employs persons to do maimtw mce, construction or repair wont 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 license or permit to operate a business or *o construct buildings in the. commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insurance covera."Qe required" Additionally, MGL chapter I52, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall eater irrto any contract for the perfoissrarice of public work- aural acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the coarnracting authority." . Applicants Please fill out the workers' compensation• affidavit compie✓tely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) weed phone numbers) 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 requved to carry workers' co=npensation 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 •Ewe 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. listod below, Sel{insured c„t., s �. self insurance-Iicanse number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete acid printed Iegl-biy. The Department has provided a space at the bottom of the affidavit for you to fill out in tiu event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which %viII be used as a reference number. In addition, an appikant that must submit multiple pwmitAicmm applications in any given year, need only submit one affidavit indicat ngcurrent policy:infonnation (if necessary) and under -"Job Site Address" the applicant should write "all locations in (city, or town)." A copy ofthe affidavit that has bom.officially stzrnped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for fikwe permits or licenses. A new affidavit must be filled out each year. When: a home owner or citizen i obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said persorI is NOT required to complete this affiidaviL The Office of lnvestipations 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 Commonvrealth of Massachusetts Depart mont of }.mdustW Asci d=ts Office of Investigations 600 Washington Street Baskm, MA 02111 TeL # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7745 www.mass.gov/dia -6 0 Date/ TOWN OF NORTH ANDO)kk —v PERMIT FOR WIRING This certifies that ... ............................................................... .. ...... .................... has permission to perform .... . ........... wiring in the building of Fatee..,... . N ort h A n. dov.e.r. ,. Mass. LELEcrR1cALNspE R Check # . "k 1\ Commonwealth of Massachusetts V. Department of Fire Services �Vw BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 90 ;7F Occupancy and Fee Checked Lev. 1/07) (leave 1,1_t, APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 5 7 C 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: 1&'2�� City or Town of: NORTH ANDOVER To the Inspector of fres: By this application the undersigned gives notice of his or her inte�on to perform the electrical work described below. Location (Street & Number) ----A< e13 Owner or Tenant 1 Owner's Address /% Telephone N Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building_ ��%%�IJ`f�G Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters New Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: I No. of Recessed Luminaires INo. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers o. of Dishwashers No. of Dryers No. of Water KW Heaters Hydromassage Bathtubs No. of Ceil: Susp. (Paddle) Fa No. of Hot Tubs Swimming PoolArbndye ❑ No. of Oil Burners No. of Gas Burners No. of Air Cond. Tot. To; Space/Area Heating KW Heating Appliances I' No. of No. of Signs Ballast No. of Motors Total I following table may be waived h„ tho Im.,o...,,- ,.r ur._-- ns No. of Total Transformers KVA Generators KVA [n- �rnd. ❑ 0-o mergency ig g Batte Units FIRE ALARMS No. of Zones No. of Detection and l Initiatin Devices sNo. of Alerting Devices ._. ................. No, of Self -Contained Detection/Alerting Devices Local Municipal ❑ Oe Connection :W Security Systems:* No. of Devices or Equivalent s Data Wiring: No. of Devices or E uivalent-!�a IP Telecommunications Wiring: No. of Devices or E uivalent -V Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pain . a d penalties of tthat th ormation on this application is true and complete. FIRM NAME: a LIC. NO.: Licensee: Q Signature (If applicable, ent r "exem t " i t : e nu LIC. NO.: Address: Bus. Tel. No.: Y 7 3 ,ter *Per M.G.L .147, es 57-61, security work requires Department of Public Safety "S" License: Alt. Licl. No� � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent Owner/Agent Signature Telephone No. PERMIT FEE:6c� a www.massgov/dia . Workers' Compensation Inshmnce Affidavit: Builders/Contractors/Electricians/Plumbers nniir•ant Tnfrn......:�.:.... Name (Business/Organization/Individual)•_ , �e" Address:"'lo r City/State/Zip: r / /�' Phone #: . The Commonwealth of Massachusetts k� ! •-. • I Department of Industrial Accidents Office Investigations i of ship and have no employees These suli-contractors have 600 Washington Street working for mein any capacity, workers' comp. insurance. [No workers' comp. insurance 5. p ❑ We are a corporation and its Boston, MA 02111 www.massgov/dia . Workers' Compensation Inshmnce Affidavit: Builders/Contractors/Electricians/Plumbers nniir•ant Tnfrn......:�.:.... Name (Business/Organization/Individual)•_ , �e" Address:"'lo r City/State/Zip: r / /�' Phone #: . Are you an employer? Cheek.the appropriate box: .711 f 1. I am a employer with 4. ❑ I am a general contractor and 1 Type of project (required): employees (full and/or part-time).* have hired the sub -contractors 2.❑ 1 am.a:sole proprietor or partner_ listed on the attached sheet. t 6. ❑ New construction 7�emodeling ship and have no employees These suli-contractors have 8. ❑ Demolition working for mein any capacity, workers' comp. insurance. [No workers' comp. insurance 5. p ❑ We are a corporation and its 9. ❑ Building addition required.) officers have exercised their 3. ❑ I am a homeowner doing 10.❑ Electrical repairs or additions all work right of exemption per MGL myself. [No -workers' comp. c. 1.52, § I (4),'and we have no insurance 11.❑ Plumbing repairs or additions 12, Roof ❑ repairs required.] t .employees. [No workers' 13.❑ Other comp. insurance required.] 'Any applicant filar checks bo> # I must also fill out the section below showing their worketti' compensation policy information. t Homeowners `who submit this affidavit indicating they are doing all work end then hire outside this box must connectors must submit a new affidavit indicating such. ;Contractors that check this an additional sheat showing the _rt me of the sub.contmetum rqd their s orkers' comp. policy infamiaiion. I am an employer that rs.provrdcng:workers' compensation inSUFaRcefor my employees. Below is the informati in. policy and job site _ / Insurance Company Name: �05z!i� / Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address:_ /� �City/%t--/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under th and penalties of perjury that the information provided above is true and correct Si tore: Date. ��09 Phone #: t EEOther only. Do not write in this area, to be completed by city or town officiaL Town: Permit/License # Use (circle one): Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector �, son: Phone #: V 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 airy 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-contractor(s) name(s), addresses) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If 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, notthe 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 numberlisted below. Self-insured companies should ente, 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 futum permits or licenses. A new affidavit must be filled out each year. When a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT. required to complete this affidavit The Office of investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Fax # 617-727-774 Ai Revised 5-26-05 vvww_mass.gov/dia I