HomeMy WebLinkAboutMiscellaneous - 120 WATER STREET 4/30/2018 (2)Date......A ........................
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
....
. ...... —
This certifies that ................ 14 ... ( ............................................................
has permission to perform ........... 5.— Z775�� .... .........
wiring in the building of ..... . ........
Sum
at ..... ...... 5 .. ........................ -
, , North Andover, Mass.
Fee. 5.................. Lic. No.... �.5—& .................. ... .........1.. .............. ..... ..
E'Llr(CrPICAL INSPECTOR
Check #
910.4
I
Lanvrwruvaa& n1 Nla94acicu3alb Official Use Only
Permit No.
gL, T_1JeParlmenl o�,}ira �ervic¢s �'-
Occupancv and Fee Checked
'-q P, BOARD OF FIRE PREVENTION REGULATIONS fRev. i/07] (leave blank)
AhPLICAT'01" FOR PERMIT70 PERFORM ELECTRICAL WORK
All ':'ork tl ''.c perfoenea in a. ord dice wiih,the Massachusetts Electrical Codc (MEC), 527 CMR 12.00
:'(P.1,EASEPRIN7'1T!rdK 0R TY *P E ALL I, F0.1Zti 4T10N) Date:_LO
City or ; own of: Allo :L/ /In ol/E To the.Inspector of Wives:
By this application the undersigned gives , otice �f his or her intention to perform the electrical work described below.
Location (Street & Nurnber)12o li erA-5;e
Owncr or T c n a n t D 14xole S7Rt-55-7-/7PR%),1r--L Telephone No.97r--11-)0�
Owner's Address
Is this p:•.rmit iu conjunction with a building permit?
Purpose of Building
ng c. -ic_ .k -n / Vol,.s
Amps / Volts
Number of Feedr.rs and Ampacity
Lucar;on and Nature of Proposed Electrical Work:
Yes ❑ No (Check Appropriate Box)
Utility Authorization No. .
Overhead ❑ Uadgrd ❑.eters
Overhead ❑ Undgrd ❑ No. of Meters
IJ C' -t; t` t j Or -it C AL) -S 1
in nnlorinn nitha ! llnwtna tnhie -- he —;—d by tha r s .•..riV:_.-
Teo. of h?cccs:�Lumivaires
No. of Ceil.-Susp. (Paddle) Fans
o• ° o1a .
.cd
Transformers ;t� A
No. of I-umiva.;.rc Outlets
No. of Hot Tubs
Generators KVA.
No. of L-,.mioaive;
Swimming Pool Above El ❑
d. rad.
o. o Emergency rgn tag 71
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
o. of .Detection and
Initiating Devices
No. of Ranges
Total
No. of Air Cond. 'Pons
No. of Alerting Devices
No. of Waste Disposers
_
Heat Pump
Totals:
um jer
ons
o. oSelf-contained
Detectioa/A.lertin Devices
No. of'Disbwashers
_
Space/Area Heating KW
Local ElMunicipal El Other
Connection
No. of Dryers
Heating appliances KW
Security Systems::*
No. of Devices or Equivalent 3
No. of Water I�,
Heaters
o. ofFO—OT—
Signs Ballasts
Data Wiring:
No, or Devices or Equivalent
No. Hydromassage BathtubsNo. of Motors Total HPe ecommunications.Wrrrng:
No. of Devices or Equivalent i
OTHER:
Attach additional detail ifdesired, or as required by the Inspector of Wires. '
Estimated Value of iEle,:.1.,icaT.-Vork: _ (When required by municipal.policy.) , `1
Wort: to Start: to be rc.Iussted in accordance with MEC Rule 10, and upon•dompletion.
INSUR,INCE C0VERA.•'-7E: Unless waived by the uwr,dr, no permit for the performance of electrical work may issue unless
tnc litensec provides proof rf 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 01,4H: INSURANCE 0 BOND ❑ OTHER ❑ (Specify:)
1 certify, under thepains and penalties ofperjury, that the information on this application is true and complete.
FIlUd NAME: _ (-,y —� Se Co o S -c f- a es LIC. NO.: -LIS (.T—
Licensee: MCC Y- Signature_ LIC. NO.:
(/f applicable, enter "exempt" in the Ircenl umber line.) Bus. Tel.
Address: I S, CI_Ir)T6-n 2. . k \\\s. Alt. Tel. No.;
"Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License:. Lic. No. QQX��1�j�
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By rry signature below, I hereby waive this requirement. I am the (check one) El own er owner's a ent.
Owner/Agent , : PERMIT FEE: S J
Sisnature _____ _ _, Telephone No. .
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Location
No. Date /U M09
TOWN OF NORTH ANDOVER
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Certificate of Occupancy $ /dd
cMust< Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 2 .'
22516
Building Inspector
ow».
ger. .,..,, •.�
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Permit # 180 (9/312009) Date: October 8, 2009
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 120 Water Street — Park Street Travel
MAY BE OCCUPIED AS Office Tenant Since ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH
OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to: 120 RCG NA Mills LLC
120 Water Street
North Andover MA 01845
Building Inspector
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BURT, -M I'LL
October 5, 2009
Mr. Gerald Brown
Inspector of Buildings
Town of North Andover
1600 Osgood Street
North Andover, MA 01845
Re: Park Street Travel Tenant Fit -out
Second Floor, Building'l 1
East Mills, North Andover
Burt Hill Project 07804.15
Dear Mr. Brown:
The tenant improvements for Park Street Travel on the second floor of Building 1 1, 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 3, 2009
Permit #180, 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
(in�da S. Smiley, AIA
Senior Associate
Phone: 617.654.6003
cc: Kieran Whelan
David Steinberg
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
----------
57, - e,,p
Date .............
—�.....................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
.4
This certifies that ... I .... ........... .. .... . ....... ...............
......................
rm ............................. ............ .................
has permission to �,Tf.".�� 'Z
wiring in the building of....... 5� .................... / ...................................................
at......................... a ............................................. North Andover, Mass.
Fee..... . Lic. No4�Ar%.,Z ...............
A�I �Zi��PE
Check #
9
000
Commonwealth ofassachusetts
•�'`� MOfficial Use Only
Department of Fire Services FOccupp
mit N.
M
BOARD OF FIRE PREVENTION REGULATIONS ancy and Fee Checked °=
[Rev. 1/07] Qeaveblank
APPLICATION FOR PERMIT TO PERFORM° ELECT I,C�+ /��
All work to be performed in accordance with the Massachusetts Electrica] Code (M C), 527 R/" 12.00AWORK
O r Y O R K
(PLEASE PRINT IN INK OR TYPE ALL INFORM14 TION) Date: D3
City or Town of: NORTH ANDOVER
By this application the undersi ed To the inspector of Wires:
gn gives notice of his or her intention to pea the el 'c work described below.
Location (Street &Number) �/�
Owner or Tenant 01-7
Owner's Address Telephone No.
Is this permit in conjunction with a builddiin�njj,�p,ermit? Yes
Purpose of Building 4;/%,ro�e�Y��� No ❑ (Check Appropriate Bog)
Utility Authorization No.
Eiisting Service Amps / _ Volts
Overhead El Undgrd 7 No. of Meters
New Service Amps _ / Volts Overhead
❑ Undgrd ❑ No. of Meters
Number of Feeders and A.mpacity
Location and Nature of Proposed Electrical Work:i
Com letion of the folloWin table may be waived by the Inspector of Wires.
No. of Recessed Luminaires No. of CeiL-Sus; No. of
y p. (Paddle) Fans Transformers Tota! .
No. of Luminaire Outlets TKVA
No. of Hot Tubs Generators KVA
�l No. of Luminaires Swimming Pool Above Im- o. o mergencyIEFgHiii
d Md. Battery Units
No, of Receptacle Outsets No. of On Burners
FIRE ALARMS No. of?ones
No, of Switches �' No. of Gas Burners No. of eteciion and
No. of N
Ranges TInitis • Devices
g o. of Air Cond. Total
Tons No. of Alerting Devices
No. of Waste Disposers Heat Pump umber Tons KW o, of Self Contained
Totals: _` '_� - Deteeiion/Alertin Devices
No. of Dishwashers Space/Area Heating KW Local Municipal
Connection
No. of Dryers Heating Appliances KW SOther
ecurity Systems:
No. of Water No. of No. of Devices or E uival
KW Data Wiring: nt
e
Heaters No. of
Si s Ballasts .
l No. of Devices or E uivalent
No. Hydromassage Bathtubs
No. of Motors Total Hp Telecommunications Wiring:
OTHER: No. of Devices or Equivalent
Estimated Value of Electrical Work: Attach additional detail!f desired, or as required by the Inspector of Wires.
Work to Stark(When required by municipal policy.)
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 d pen s oof prye mat itnh information
FIRM NAME: this application is true and complete
Licensee: /r Signator LIC. NO.:
(If applicable, enter exemp " in license nu er lie LIC. NO.:
�W
Address: _�� �f�� j % � �j� ,� „ us. TeL No.: % 97
*Per M.G.L c 147, s 57-61, security work requires Dty Tel. No.: 7
OWNER'S INSURANCE WAIVER: I am aware thathe Licensee doles noSaft have'the Icens : Lic. No.
rance normally
required by law. By my signature below, I hereby waive this requirement I am the (check one) 0 owner coverage owner's agent
Owner/Agent
Signature Telephone No. PERMIT FEE: S
The Common wealth of Massachusetts
Department of .Industrial Accidents
Ogee of Investigations
600 ff-�ashington Street
Boston, M4 02111
t t
www mass govldia .
Workers' Compensation Insiu-ance Affidavit. Builders/Contractors/Electricians/Plumbers
?piicant Information n_s_4 r _ ..
Nellie (Business/Organ ization/Individual):
Address:
City/,State/Zip: Q
Phone #:.✓� ��(� ��/��
Are you an employer? Check the appropriat�box-m�
I•{I
am a employer with
4, eral contractor and I
employees (full and/or part-time).*
2. ❑ ! am a sole proprietor or
have hired the sub -contractors
listed
partner.
on the attached sheet, t
ship and have no employees
These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
3. ❑ I am a homeowner doing
officers have exercised their
all work
right of exemption per MGL
myselL [No -workers' comp,
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required_]
'type of Pref (required):
8. ❑ New construction
7. Remodeling
8[ Demolition
9. ❑ Building addition
10. El Electrical repairs or additions
I I.❑ Plumbing repairs or additions
12.❑ Roof repairs
I3.❑.Other
t
'Any applicant that checks bo)C #I must also fill out the section below showing their workers' compensation policy information.
homeowners who submit this affidavit indicating they ars doing all work and then hrte outside connectors must submit a new affidavit indicating such.
;Cottnactors that check this box must attached an additional sheet showing. the creme of the su
b -contractors and their evorkers' camp. policy inibrmation.
1 am an employer that is prottrdi►tg:workers' compensation insurance for nry. employees: Below is the policy and. job site
'information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address:
jAttach a copy oCity/State/Zip: f 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
that the information provided above is true and correct
Offtciat use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. CitY/TOWn Clerk 4. Electrical Inspector 5. plumbing Inspector
6. Other
Contact Person: Phone #:
Information a end 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 or more
of the foregoing engaged in a joint enterprise, and includirag the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, associatioir 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 to construct buildings in the commonwealth for any
applicant who has cot produced acceptable evidence.of compliance with the insurance coverage required"
Additionally, MGL chapter 152, §25C(7) states "Neitber 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 toyour 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 requiredto carry workers' eorrrpensation 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 nurnber. 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 lnvest getions has to contact you regarding the applicant.
Please be sure to fill in the permittlicense number which vvilI 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 i
policy information (if necessary) and under, "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of 6e affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that valid affidavi
tt is on file for fume 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
I?epartrnent of Industrial Accidents
Office of Lavestibations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-977-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia