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HomeMy WebLinkAboutMiscellaneous - 120 WATER STREET 4/30/2018 (13)" 9766 Aate ... -/6 ..- ....... h� .............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... �7 . ........... . ..... ............z4� . ........... . ........ ......... has permission to perform ..... :1>7.4Z-- I ...................... . ............ wiring in the building of ../42P.............T`'.:?........ at .... E S-/ 'aw'd �� rl.'Ow? ............. ..... . ........................... orth Andover, Mass. Fee.0�� ........... Lic. No. ............. .. .. .... ... ! . .. ....... E L Jcc �11 Nww 2 r�ooip #71 L Check # -11`0. 2012 Massachusetts EIectrical Code Amendments 527 CMB 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. 01c. 166, § 32, an electrical permit shall he 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 shallbe limited as to the time o£ongoing construction. activity, and maybe deemed_by_thelnspector-of_Wares abandoned-and.imvalid,if-he—. or she has determined that the authorized work has not commenced or has notprogressed 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 j&'growth and long -tern 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 ofreal 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 I5, 2012. Permit/Date Closed: ** Note: Reapply for new permit ❑ Permit Extension Act — Permit/Date Closed: ' \ N Commonwealth of Massachusetts official Use Only Department of Fire Services Permit No. �7 �Q p 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: 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) W4PFA L-10-5— Owner or Tenant L"p?OAT , Co M, Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No' (Check Appropriate Boz) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead Undgrd No. of Meters New Service Amps / Volts Overhead Undgrd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: !'...».,leti.,., nftho fMnwina tnhte may he waived by the InsDector Of fires, No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans O. of Ota Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators K -VA No. of Luminaires ove - Swimming Pool d. nd. No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones o. o Detection and No. of Switches, No. of Gas Burners Initiating Devices ces No. of Ranges No. of Air Cond. Tans No. of Alerting Devices Heat Pump umber Tons KW No. of Self -Contained No. of Waste Disposers Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local municipalOtherOther Heating Appliances KW ecunty ystems: E No. of Dryers No. of Devices or uivalent No. of Water, Heaters No. o Si Ballasts s Data Wiring: No. of Devices or Equivalent Telecommunications irmg. No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or E uivalent OTHER: —.t h„ rho tnvmrmr nfWires. Ait u:a uuutigu A ucw.. ti "w.. —, — .......y.... __ — .. _- --- Estimated ._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. A CHECK ONE: INSURANCE BOND OTHER (Specify:) K 3" I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: �— LIC. NO.: Licensee: o S £ Prs PLOSS) Signature?-*� (If applicable, enter "ezem t" in t e ltcense number line.) Q Bus. Tel. No.: 7 g/ Address: t Z 4 S D 5 -FU to S % , 4/Ll I i 1"D L� I D 6J � y� 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 Telephone No. PERMIT FEE. $ Signature p Date. - �/ r . TOWN OF NORTH ANDOV PERMIT FOR PLUMBIN This certifies that .. �.? �'a<<' . .... �� /1 ?� ` , he/...... . has permission to perform .. l S..:...... ............ . plumbing in thefbuildings of .... ........I................. at ... :ccf,,a. P.. �-� .<4 �� H f .?` ..... . , North Andover, Mass. Fee. . A .r. . Lic. No: /. �. f l�. ? .. ....... C.. _ .. kLUMBING INSPECTOR Check H 8204 A MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS a./ Rcir ^- Date Q $ J009 Building Location /).Oyl R#E 57 Owners Name �Le Permit # s� iG Y '[� 1 3 6 %Amount Type of Occupancy C OM M Q rC i A L New Renovation Replacement Plans Submitted Yes No ❑ FTXTT TR Fc (Print or type) Check one: Certificate Installing Company NameLTA MO- S rorrmc- P+N ❑Corp. Partner. G9Firm/Co. Name of Licensed Plumber: J ! 11 f'f .g � Ggrp /a/ C— T Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy M Other type of indemnity ❑ Bond ❑ 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 El 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 r this application will be in compliance with all pertinent provisions of the Mas sac setts State Code and 142 of the General Laws. By'ign cense um er Title e of Plumbing License City/Town icense um er Master Journeyman ❑ APPROVED (OFFICE USE ONLY ` The Common wealth ofMassachusetts l� Department of .industrial Accidents Office Investigations of �a 600 lir ashirigton Street ti � Basion, MA 02111 t Workers'Compensation Iwww massgnvltia A icantIaformaoion uurance Affidavit Builders /Contractors/Eieetricians/pl.ambe rs Please Print L 'b Nal.n e(Bustness/brgani&fiOn/Individual): r� e le i. W Address: ,�� o% — 3—AreCity/state/zip: /erg 3Q79 Phone #4 97S 5/-� 3— Amyou an employer? Ch eck.the appropriate box: 1. ❑ I- am a employer with 4,Type of pralect (require(): ❑ I � a general contractor and I - employem (fun and/or part tune).* 2. ] I am .asole proprietor. or have hired the sub -contractors 6. ❑ New construction . listed partner- ship and have no employees on the attached sheet = 7. ❑ Remodeimg These sti&contractots have working for me in any capacity, [No workers' comp. insurance workers' comp. insurance. 8. Q Demolition 5. ❑ .Weare: a corporation and its 9' ❑ Building addition requirecL] 3. ❑ I girt a homeowner doing officers have exercised their 10.[]Electrical repairs or additions all work myself~ [No•workers' comp. right of exemption per MGL I LIE jE Plumbing repairs or additions G 152, § 1(4), and we have no insurance aMquired.] t .employee& [No workers' 12.❑ Roof ((pairs 1 comp. insurance required.] 13.❑.Ctier 1 *Any cowsaMliem brat Checks bortf# 1 moat also fill out the section Wow showing their worka t i:om t Homeowners who sabmif this affidavit indicating they are tlom PMsu� policy information.' an lct n ntat w that check this box mint attaoleed an adt itioaal shoat showingend �� hire outside contractors must`suimtit a now afndavit indicating such. the name of the sub-cromractm and chair wofka , -rrc. Policy in iornretion. t' lFiiE fFis employer tltaZ ;-pro . .� r.ra!d4 rg:warkers• infartnatfor& r coWensadotn jnsur=Ce or -f �' entPlaYeM Below is the policy and job Insurance Company Name: ' site . Policy # or Self -ins. Lie. 9: Expiration Date: Sob Site Address:._; � � t) til/ ytw- rz �-�'"' coon � ' Attach a copy of the workers' City/State/Zip:�J ,'4 /e M A ' / . 0 3b peasatioo; policy declaration page (showing tltt paiicy number and expiration date] Failure to secure coverage as required under Section 25A of MC3L c. 152 can lead to the imposition of criminal penakies of a fine up to $1,500.00 and/or one-year imprisonment, as well las civil penalties in the fonn of a STOP WORK ORDER and a fine In es to tions o a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D1A for insurance coverage verification. I do hereby cerci ander th ns and p f perjury that the irrfor»:aiion Provided above is pie rowed 5i tore: Date:Jz j Phone#: J �� 7 Qfj`ictal use only. Do not write is this area to be cnmpler e,d by city or town okra( City or Town: Permit/License Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Tovvn Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person;: Phone #: 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; association, corporation or other legal entity, or any two ormore of the,fomgoing engaged in a joint enterprise, and includi"g the legal representatives of a deceased employer, or the receiver orbustee of an individual, partnership, associatioin 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 sucb 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 *e construct buildings in the commonwealth for any applicant who has not produced acceptable evidencezir compliance with the insurance coverage required." Additionally; MGL chapter 152, §25C(7) states `Neither t1he commonwealth nor any of its political subdivisions shall enter into any contract for the pmforannce of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the coyitm eting 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). Bond phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, an not requiredito 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 Eie sure to sign and'date the affidavit. The affidavit should 1 be returned to the city or town that the appilication for the permit or license is being requested, northe Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' oorttperksaticrn policy, please -call the Department at the nrnnber. iistcd below. Self insured c-ompaninc should enter th= / self insurance-lical se number on the appropriate line.11 City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department hes 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/licrose number which %%-ill,be .used as a reference number. in addition, an appikant that must submit multiple permit/licm= applications in any given year, need only submit one affidavit indicating current policy :information (if necessary) and under ".lob Site Address" the applicarrt should write "all locations in (city or town)." A copy of -the affidavit that has been officially starnped or marked by the city or town may bee 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 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 person is NOT required to complete this affidavit The Office of Inves i.aptions would bile 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 13ndustW Accident Office of Investigations 600 Was]aington Street Boston, MA 02111 TeL # 617-727-1900 ext 406 or 1-9.77-MASSAFE 1Zevised 5-26-05 Fax # 617-727-7744 www.mam.gov/dia Date ..45""&. ... .01 .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... ............................................... has permission to p erform... I ........ 4 - /- .............................. wiring in the building of ... ;? ............ at ..... M ............. . .............................. . North Andover, Mass. Fee ... ...... Lic. No. A/3�� ... ELECTRICALINSPECTO Check # V` Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. CJ BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave bank 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 PRINTININK OR TYPE ALL INFORMATIOA9 Date: O 19 City or Town of: NORTH ANDOVER To the Inspector o ices: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) //1-4 O%2 A— Owner or Tenant Owner's Address /7///, Is this permit in conjunction with a building permit? Yes Purpose of Building Existing Service Amps / Volts New. Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Telephone No. No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters No. of Recessed Luminaires r1c uuuw,n No, of Ceil: Susp. (Paddle) Fans iaoee may oe waived by the Inspector of Wires. No, of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above I- ❑ nn❑ o. o mergency ig g grnd. rd. B atte 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 I.nitiatin Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number .._......................._ Tons KW No. of Self. -Contained Totals: . Detection/MerDevices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal Other ` No. of Dryers Heating Appliances KW Security Systems:* No. Devices No. of Water Heaters KW No. of No. of Si s Ballasts . of or E uivalent —Data Wio. ring:Q or E uivalent d No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Eq uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee. provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penes of perju , that the infor tion on this a licadon is true and complete. FIRM NAME: LIC. NO.: Licensee: ignature LIC. NO..tK&? (If applicable, enter "exe " inens nu er l Address: i ��� Bus. Tel. No.: � 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: $ A 'A jpd f5i44- 2 j I - ❑ I am a employer with 4. ❑ 1 am a general contractor and I The Commonwealth of Massachusetts k� l Department of Industrial Accidents Office of Investigations t# ship and have no employees "4 600 iEashington Street rt. Boston, MA 02111 5. ❑ We are a corporation and its required.] 3. ❑ 1 am a homeowner doing all work f' 1 www.mass.gov/dia . Workers' Compensation Imitrance Affidavit: Builders/Contractors/Eiectricians/Plumbers AtinIicant Information Pie— Print LeAbiy Name (Business/Organiza6on/individual): Address: City/.State/Zip: Are you an employer? Check the appropriate box: I - ❑ I am a employer with 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* 2.[] I am asole or have hired the sub -contractors listed t proprietor partner_ on the attached sheet ship and have no employees These stt&contractors have working for me .in any capacity, workers' comp. insurance. [No workers' comp, insurance 5. ❑ We are a corporation and its required.] 3. ❑ 1 am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No -workers' comp. c, 1.52, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required_] *Any applicant that checks boi#1 must also fill out the section below shth ' -1, c Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1 I. Plumbing repairs or additions 12.[] Roof repairs ow.tng etrwo eompensation policy mtormation. 13.❑ .Other t rs Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. •lconmwtors that check this box must attached an additional sheer showing the name of the sub•conteactors and their workers' conip• policy information. Jam an employer that is providing:warkers' compensation insurance for my. employees: Below it the policy and job site . information. Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: 1 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration dated 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 of perjury that the information providedobeyeA' true and correct. 7 Harp• �j/ JO A!0 4 Ofj`iciat use only. Do not write in this area, to he 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 S. 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." tN 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 requiredto 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 returped 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 nu. ber. 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 permittlicense 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. # 617-7274900 ext 406 or 1-8.77-MASSAFE Fax # 617-727-7744 Revised 5-26-05 www.mass.gov/di.a f '" Date............. `5.... .............. 3a ;�:`° :• e~ppL TOWN OF NORTH ANDOVER p PERMIT FOR WIRING n, t -'tet- • ♦ °1�ow�r�o•1•,�,�j♦ 71, �,_i' SSAGMUS� /." This certifies that ..���`... / �4� has permission to per�form........ .....................:.r'`i�....................................... the building wiringin of .:....:......... ................................................................... )�� at./ .............',........................:.................... ....... ,North Andover, Mass. j�� �- � Fee?d`_'.�.......... Lic. No�.'Y& .............'. . . .......... ELECTRICAL INSP Check # 8741 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked ;ev. 1/071 nPAVP m..U� 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 WINK OR TYPE ALL INFORM4 TION) Date: 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) IZO W0j, r� Owner or Tenant SCG 6 C: Telephone No. 01 �g� nod s Owner's Address �+ �il�1^ �'�, i �n� �w�Du2r Is this permit in conjunction with a building permit? Yes Purpose of Building�r -�14 _ UP Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and.Ampacity No Ll (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ Location and Nature of Proposed Electrical Work: No. of Meters No. of Meters Estimated'J uescrea, or as required by the Inspector of Wires. 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 ❑ (Specify:) I certify, under the pains and enalkes o p ) p fperjury, that the information on this application is true and complete FIRMNAME:_6kN4.RU 1�,c1+^tz= LIC. NO.: 4 Licensee: ZA.- VO VP- Signature (If applicable, enter "exempt " in the license number line.) LIC. NO.: Address: Iov- a Bus. TeL No.:_617-ja -�� *Per M.G.L c. 147, s. 57-61, secu ty work re uir s „ „ Alt. Tel. No.:B-rJ2>�4k0 Q apartment 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: $ 1,-2,S�� 41 *141, 417i ilM The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 014yhingion Street Boston, MA 02111 t www.nwss.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information w Please Print Le-� l Name(Busincss/prgmization/individual): Address: 61A (y�tr, i fns v City/State/Zig: Phone #:_. F z- 4 2 -- 7 D R 3 sat' Are ou an employer? Checktthe appropriate box: II am a employer with 4. ❑ 1 am a general contractor and I (full and/or part-time—).* have hired the sub -contractors 2memployees I am.a.sole proprietor or partner_ listed on the attached sheet. 2 ship and have no employees These suli-contractors have working for me .in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.) 3. ❑ 1 air a homeowner doing officershave exercised their all work right of exemption per MGL myself. [Nonworkers' comp, c. 1.52, § 1(4),' and we have no insurancerequired.] t employees. [No workers' comp. insurance required.] t"Any applicant that checks boz' # Imam also fill out the section below showin their workers' 6om Type of profs (required): 6. ❑ New construction 7. Remodeling 8. ❑ Demolition 9. ❑ Building addition 10 -El Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other B pen ron pomy mtormatton. Homeowners who submit this affidavit indicating they are doing all work and then hits outside contractors must'submit a new affidavit indicating such. 1conautors that check this box must attached an additional sheet showing the name of the sub -contractor; and their workers' comp. policy infommtion. awn. an enwioyer that lsProviding:workers' compensation insurance or P f my employees: Below is the information. pOlfey and job site Insurance Company Name: �Q� Cx to �— Policy # or Self -.ins. Lie. #: Expiration Date: Job Site Address: ail to H 7* 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 farm 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. ! do hereby certijy�ndein and penalties of perjury that the information provided above is true and torted Difficial use only. Do not write in this area, to be completed by city or town. officio( City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector 5. Plumbing Inspector 6. Other UContact Person Phone #: Information a nd Instructions Massachusetts General Laws chapter 152 requires all emp )overs 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, 525C(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 requiredl 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 app. iication 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 nurnber. listed below. Self-insured companies should enter their self rrsurance license cumber 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 NviII 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 indicatingcurrent 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 1-977-MASSAFE Revised 5-26-05 Fax # 617-727-774 www.mass.govldia Date .... �.a:7.Z.44- TOWN OF NORTH ANDOVER PERMIT FOR WIRING .............. This certifies that ........................ ....................... has permission to perform .......... .. . ............................................ wiring in the building of -A. -C. 4n......'//. ..... ............ at .......... J, ............................... . ...... North Andover, Mass. .. ..... . Fee .17!5 .` ........ Lic. No. .............. .fel........ LECTRICAL INSPECTOle Check # Commonwealth of Massachusetts Official Use Only Department of Fire Services PermitN°.y3 1WOccupancy 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 CM 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1A10 y Ac).__0 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to erform .the electrical work described below. Location (Street & Number) /& Lrt !w A). Owner or Tenant Owner's Address /;7 Telephone No. ! 11742,y �f 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:��� ComDletion of the follnwina tnhly mm, by u—i,,,d h„ "ho TF onon#n ^rw;v No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above 0 In- F-10. rnd. rnd. 1 o , mergency ig g 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. Ton Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number Tons _ . KW • " ***'-' No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal [I Other No. of Dryers No. of Water Heaters ' Heating Appliances KW No. of No. of Signs Ballasts Security Systems:* No. of Devices or Equivalent Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 16'12-31� 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:) Icertify, under the pains andpenalties ofperjury, that the information on, is application is true and complete. FIRM NAME:' /�� , LIC. NO.: Licensee: ,� !ate �'l�`' Signature (If applicable, enter "exem t" in the license number line.) ' �—®�J% . /p�//�/✓�� Bus. Tel. No.: Address: �� � .j' < zer 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: $ 4L y The Commonwealth of Massachusetts 1 Department of Industrial Accidents Office of Investigations 600 Washington Street a Boston , MA 02111 www-Mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Elect ricians/Plumbers Applicant Information Please Print Lembly Name (Business/Organization/individual): Address: City/State/Zip: Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10:0 Electrical repairs or additions 1.1.❑ Plumbing repairs or additions 12.0 Roof repairs 73-ElOther mg t etr workers compensation policy information. t Homeowners who submit.itiis affidavit indicating they are doing al! work arid then hire outside contraciors must submit.a now affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am ann employer that is providing workers' compensation insurance for my employees. Below is the information policy and job site Insurance Company Name: Policy # or Self -.ins. Lic. #: r Expiration Date: Job Site Address: / ��T I�l''� 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 aid penalde of perjury that the information provided above is true and correct f Official use only. Do not write in this area, to be completed by city or town official City or Town: PermitlLicense # 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 #: Are'you an employer? Check the appropriate box: I . ( I am a employer with 4. ❑ 1 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 area corporation and its required.] officers have exercised. their ,ts 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 1, 52, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 1 must also fill out the section below show' h Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10:0 Electrical repairs or additions 1.1.❑ Plumbing repairs or additions 12.0 Roof repairs 73-ElOther mg t etr workers compensation policy information. t Homeowners who submit.itiis affidavit indicating they are doing al! work arid then hire outside contraciors must submit.a now affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am ann employer that is providing workers' compensation insurance for my employees. Below is the information policy and job site Insurance Company Name: Policy # or Self -.ins. Lic. #: r Expiration Date: Job Site Address: / ��T I�l''� 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 aid penalde of perjury that the information provided above is true and correct f Official use only. Do not write in this area, to be completed by city or town official City or Town: PermitlLicense # 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 ti insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to cant' workers' compensation insurance. If an LLCor LLP does have ._ x 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 lava 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 permitliicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The 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 # 617-727-7749 www.mass.gov/dia i i� Date ...... -.f..-..- .. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .....(` has permission to perform .......... ...................................................................... wiring in the building of�!2-' % OT _ G�J�� ....y ......................... ...... Z0 tuore � at........................................................................ , North Andover, Mass. Fee.................... Li.. No....:......... ............... ... .........`....... ELECTRICAL INSPE OR�~ Check # 8347 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked r 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 5 7 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector.of W res: By this application the undersigned gives otice of his or her intention to perform the electrical work described below. Location (Street &.Number) /.?/�/j� Owner or Tenant Owner's Address Is this permit in conjunction with a building ermit? Ygs Purpose of Building Uy�t�/U�B% Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Telephone No. No LJ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters 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 G✓ Above ❑ In. ❑ Swimming Pool rnd. grnd. o. omergency 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 Wtiatin2 Devices No. of Ranges Total No. of Air Cond. Tons — No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Imo' Security Systems:* o. of or E uivalent No. of Water Imo' Heaters No. of No. of Signs Ballasts Data Wiring: g' No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pa�' s,94d pedndes of rju, that the in o on on this application is true and complete. FIRM NAME: C�P(/il�� /^ LIC. NO.: Licensee: LIC. NO.: (If applicable, enter exempt' in license num er Itn us. Tel. No. Address: ��/- — Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S' icense: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required bylaw. 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: $ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 V www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): IN Address: �/ 66_7'3. City/State/Zip: Are you an employer? Check the appropriate (Yox: 1.p'I am a employer with _40_ 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.] f 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 12.7 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: 6�%!y�� (,� 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 of perjury that the information provided above is true and correct. Phone #:lor ��� �q�j l Official use only. Do not write in this area, to .be completed by city or town offwiaL 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 #: �6 Location"- -• NO. -Z `� Date 171-1-9— Q de TOWN OR NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit. Fee $ Foundation `Permit Fee $ Other Permit Fee $ TOTAL $ " Check # 1930... " �j` Building Inspector% 0 N 2 A 0 M 0 I E U 0 0 y x 0 R! IN In Z I p w 9 "a El ca a O 9 ►a la a� U crs 0 0 0 3 U on 4-+ O U Cd z 4-+ d a� y w~ado SM 'A 00 .0'a o..� O �..� 3 w Q.'0 c�a ho 40. o 4r a tn Ixw Uv,AO �w y b u .� 0 0 'd 400. 00 o °0.0 -0.5 O O N p N 0 O p� N U N z a v z�3 oizo la a� U crs 0 0 0 3 U on 4-+ O U Cd z 4-+ SM w. 4r Ixw Uv,AO la a� U crs 0 0 0 3 U on 4-+ O U Cd z 4-+ , Page 1 of 1 file://C:\Documents and Settings\Hazel HopkinsTocal Settings\Temporary Internet.Files\... 4/13/2007 - £Y4�i"T •.RLi Yi HIGH MUT R1 m4f t`a � �.sMu t l(9' we 40 qt � S i 11 ilff r file://C:\Documents and Settings\Hazel HopkinsTocal Settings\Temporary Internet.Files\... 4/13/2007 - tM m Y Z "7 Date ..... TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING This certifies that ....... . ..... ....... ............. . . ........ . e&.. 17 has permission to per orm wiring in the building of ....... C .. . �r:........<... .............................................. at....& -Y* 11-1-1 ...................... . North Andover, Mass. ,?V ' - * 11 Fee.". f .......... Lic. No ... ... j .. .. ............................................................ ELECTRICAL INSPECTOR Check # . /f/// �; 5334 T ``X Commonwealth of Massachusetts Official Use Only z zPermit No. ��✓ Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/991 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 i X (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 7/2/2004 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) 120 Water Street Owner or Tenant C -Port Owner's Address Job #20873 Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No © (Check Appropriate Box) Purpose of Building Utility Authorization No.. Existing Service Amps New Service Amps Number of Feeders and Ampacity Volts Overhead ❑ Undgrd ❑ Volts Overhead ❑ Undgrd ❑ Location and Nature of Proposed Electrical Work: Access Control Addition No. of Meters No. of Meters Completion of the ollowin table may be waived b the In ector of Wires. No. of Recessed Fixtures No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑ In- Elo. rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number I Tons KW No. of Self -Contained 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 Kms, Heaters No. of No. of I Signs Ballasts Data Wiring: No. of Devices or Equivalent No. a H dromassae Bathtubs Hydromassage No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. 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:) (Expiration Date) 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. I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: B & T Security Safet LIC. NO.: 1599 C Licensee: John H. Beckwith Signature LIC. NO.: (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.; 781-935-6665 Address: 18 North Maple Street, Woburn, A 01801 Alt. 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/Agent PERMIT FEE. $ O Signature Telephone No. �`