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HomeMy WebLinkAboutMiscellaneous - 120 WATER STREET 4/30/2018 (3)c cs —.,� Date ... eF ...... TOWN OF NORTH ANDOVER . PERMIT FOR WIRING This certifies that ...... 7— has permission to perform ........f.C, ................................................................... wiring in the building of ................................................. ................. ........ ........... I.: ..................................... North Andover, Mass. Fee.] Lic. No.7 ..... .. il.(*7 .......... ELECTRIC AL INSPECTOR Check # 1179 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. � 7�/ Occupancy and Fee Checked ,M BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASE PRINT WINK OR TYPEALL INFORMATION) City or Town of: NORTH ANDOVER By this application the undersigned gives notice of his or her inti Location (Street & Number) �(,(A !(j O 14- wner or Tenant .&141101711 Owner's Address Is this permit in conjunction with a building permit? Yes Date: _ To the Inspector of Wires: to perform the electricaLwork described below. /+'k,)t> v Telephone No. No ❑ (Check Appropriate Box) Purpose of Building Llg%�� L— Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: / 7- No. of Meters No. of Meters 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 y Swimming Pool Above ❑ In F1o. rnd. rnd. o Emergency Lighting Batte Units No. of Recieptacle 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 Pump Totals: Number To " R " 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 KW Heaters No. of No. of Signs Ballasts Data Wiring: /— No. of Devices or Equivalent �1 No. Hydromassage Bathtubs -j No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent %^ FoTiER- Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work td 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 thepains /a_nd�enalties ofper'ury, Itat the info zon on this application is true and complete. FIRM NAME: J'"U LIC. NO.: Licensee: ���� Signature LIC. NO.: (If applicable, enter " Le pt" in the license number line) Bus. Tel. No.: Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department ofP is 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 Fp-p"ITFEE.- $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the 1 permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed } on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an! electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass F?] Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass IN V Failed IN Re- Inspection Required ($.) ❑ Inspectors Comm ts: l Inspectors Signature: Date: FINAL INSPECTI N. Pass 0 Failed 0 Re- Inspection Required ($.) ❑. Inspectors Commen Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA. 02111 UT www.mass gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information , / / Please Print Ledbly Hanle (Business/Organization/Individual): t��_ V��1/(/ 9, 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. t ship andhave 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.❑ 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. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 requiredunder 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 $2,50.00 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. 1 do hereby certo under the pains andpenalties ofperjury that the information provided above is true and correct. Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: 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. i; 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 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 quesV.ons, please do not hesitate to give us a call. The Department's address, telephone and fax number: Tho Commonwealth of Massachusetts Department of Industrial .Accidents Office of Investigations 600 Washington Street Boston, M.A. 02111 Tei, # 617-727-4900 ext 406 or 1-877rMASSABE Revised 5-26-05 Fax # 617-727-7749 wwVV-Mass,gov/dia i Date ... :""-"..% ...... °� °'•�� TOWN OF NORTH ANDOVER 3?:' .�; • °oma . 9 PERMIT FOR WIRING ,88AC�JS�S This certifies that...................................................................:.....:...:... ............................................ has permission to perform ........... .: .. S r.. ..................... .�-::� Ct.(.<r � S� c i n wiring in the building of...............�0©.......1.���..:.....�......�O�l. ................. . at ...... ? .. ...t ?. ? ....... . T. .................................. , North Andover, Mass. Fee..--S ....:........ Lic. No. ' /. f � � ... p.. ELECTRICAL INSPECTO)Zl Check # :. r 11:830 •-�-� �� Comm€nwealthr�fMassachusetts 0fn"cialUse Only s _ Department af�f�e�etiflces Pe=ANo. _� BOARD OF Pf RE PREl1E�[T(OI� REGULATlO1�S an ea pec_ -_a ease a ur Goa'es elecfriclart's cell ; [Rev. 1/071 (leave blank) .�V contiact g & hfd pers-stit # if apPI!Cable.? APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code WCJ 527 12.00 YIEfl, 9PRI MflYX OR TYPEALLMFORMATM0) Date: 6 lacmlll City or Towne of �. ie � ✓ To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work descnir--dbelow.' Location (Street &.dumber) p �J? 2 G-( — 310 Owner or Tenant '5� cyk oo ( �L r!Q '���� Telephone No. 0 Owner's Address Is this permit III conjunction with a building permit? XeS ❑ No P (Check Appropriate Box) Purpose of Building _ Utility Authorization No. Existing Service Amps / Volts Overhead ❑ - U'ndgrd ❑ . _ .No. of Meters New -Service Amps. / volts overhead 0. Undgrd ❑ No, of Meters Location and Nature of Proposed Electrical Work: f���'� Completion ofthe following table may be waived by the Inspector of Fires - -hTorofesseil Lumin.a'. o of-CeiI._6usp_(Faan No. of -Total- ITr a�tsforrners—Iz No. of Luminaire outlets No. of Hot Tubs Generators KVA No. Of Luminaires Ahove Ia- Iimmingl'aoI d. d. oraQ o. o mergg ency. zg unszaires Battery Units No. of Switches No, of Cres Burners ofDetecfion and No. Initiating Devices No, of Ranges No..of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: I Number I Tons KW No. of Self -C iMued Detection/Ale Devices No. of Dishwashers SpaHeating KW Local F1 Municippalon [i other Connectice/Area No. of Dryers Heating Appliances KW Security Systems:* I\o. o0evices or E uivalent 1 No, of Water Heaters xWI No. of No. of Signs :Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathbibs INo. of Motors Total 11P Telecommunications Wiring: No. of Devices or Equivalent OTHER: i i I ! i 1 9 lot ach adWftb gal detail ifdesire4 or as requc sd by the Inspector of wfres- Estimated Value of lectrical Work: (Wien required by muaicipal policy.) Work to Start: -.}45A-0 Inspections to be requested is accordance with N= Rule 10, and upon completion_ INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue zmless the licensee provides proof of liability insurance including "completed operation" coverage or it substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof or same to the permit issuing of ti ce. CHECKONE: INSURANCE [] BOND 1_] OT=X (Specify:) Self Iumred fcertifyT under fire petits and pexalties ofperfury, that the ' T on ibis application is true and complei`e. )+'MM NAM: ADT LLC DBA ADT Secority %� LIC_ NO.: C-172 Licensee:_ Thomas T. Lee ignature LIC. UO.: C-172 Wap plicable P r " P,rempt" in -the 12,e nwnber 1' -.1 Bus. Tel. I�To.: Address: %_ ���/� fs2.� ` '' I �/ '0Alt. Tel, xo.:(,a' o9 ,-6—V9 --5:5iJ2 xSecurify System ContraetorLicense required for this work; if applicable, eater the license number here.: 001779 OWNER'S INSURANCE WAIVER: I mn aware that the Licensee does not have the liability insurance coverage normally required by law. By my signatwo below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent Owner/Agent --- Signature TelephoneNo. PER `FEE. cc��gg,tt y1}, �J�+1 j{'PT ��+µn �•p<�•t„-�e���_yt���ry..'{p�•_@'�_y,.,•�.���.//v:A.Yk... .W':FAAG�p;O�l':S�x].Y`'�LdY���yy��e[TT IT GTFL_E:145_. :x t55UE .Tki� EaLLQ4FENG EE fi�S °AS ' - ♦ F'-` - `rfAP5-w­ K. �" �x 1 M. r: 41' �iTY RAE 4. _ 2 y. 1; .j - .. ..._ a.u.... ._.- ._.._... _ `• _. rlt-• ... __ _ ��='_..,-.:nom-_=w _. -r_-� : �y. Comm on'N2a!-O% of itfe^-552Gilusats ^ Department of Public Safe -Y kk_jrys} •'�n,�- s- U—ro Lic_>nse- 'SS -001775 = - l ThomassLee W,ck,:Foo d Mtn E.pirafion: Corrimiss"inner " D5116(20 [4 �y. l �y. Of 199 ve?sfikal flo YIN 600 WhAdAvall swof Basog, 02,111 w.m1w.agvhfia a rd ADT Security �L' Name, Oflm,�inc-,VOrg 1 vices 100 Clinton Drive llhonra y7 -1p, pg rop 2 -- n. ri Me box., r - c ra I - C on, t F, �l C t � 0: V v I Ld I 4k y (ETll %, -propniefor or pavritx,- ms a mb­wntyactors have, ship aven s _ - _. and N .9 ernploype— vifxRiw� f " aryHOMPIMIYUrl.pa y. [Nci woi�evq' con -II). W!=H,100 COMP. MSUranN.(- Ill. ll�l k4, �� rhmA �4� N rk llomwc yself[No workc�ns' Cornp. 'p -04 - z yp of projeca. q-. !red). 61 Newoonstrac-flTin , 7n Zl 9. i Buildiug addition rj.Ej thoWwal, repa tirs oradditlons oT, or add ilid o ns; T I L] Roof r x epdl FIV ,Uw Voltage Securitv Svstem ny (I ptlt2mt Hall w9I%5Cl-_S;blDg P n� y A R. M14 5 it O.sh rl 11. 6 t fl-, a A t utio ij n b aa I o w &huw it g & b ei F v� o d, e c. 0 f. qwi s a I i, p 0 f�4?Fl1 P31 Y5. G5 ve-ho MbIllit 'ed 8110% _ivmnotl Ud stittv 4 groployms. tttllc4d thyr must povido thoir woAx-Ts'C=Ip. 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