HomeMy WebLinkAboutMiscellaneous - 120 WATER STREET 4/30/2018 (6)r -
0
v
?Location /,:?o
p
No. Date
NORTH TOWN QE NORTH ANDOVER
Certificate of Occupancy $ %�.
Building/Frame /Frame Permit Fee $
a.cNuse 9
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
22 4; 5 _
Building lnsp c�.or
M f
40
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Permit # 173 9/1/2009) Date: October 6, 2009
THIS CERTIFIES THAT
THE BUILDING. LOCATED ON 120 Water Street Ste 207 — TR Design
MAY BE OCCUPIED AS _ Office Soace 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
O
J
.co
:moo
H
i• O C
�� vV
C
1 : : Cc R
o
o m
CD
Irv; �'-4. 0CD
t•� a
3 v:
QV W �: •� v
CD
JCL
� c
o E
`NG ;
* Q Q o c
r
N '0 3
m o
•tc
N A
m
VCD 0
O '
•i -L=O
cm�a
O O
v y Z
HO N �
O C
1- O t O'er~
COD
WCOD
E
umi ' ,o
•N
CLcoo n m�o�
= W m 0 N =
F.c $ a.Z
- -. m
G
z
ip�
U
O
O
W
O
� w
Z CD
CL
R.12rs
O
CWC
' v V
V
m m
O
O � i
O d
CL CCOD
Ma
Q
c
ev
.Q O CD
co
c
ev
44
GO
v15
0-4
b •�
v
� c � �
p
a
"� 'moo `'
�
G
vy -o
�E
wO U)
x
rx iw
CO cn u)
O
J
.co
:moo
H
i• O C
�� vV
C
1 : : Cc R
o
o m
CD
Irv; �'-4. 0CD
t•� a
3 v:
QV W �: •� v
CD
JCL
� c
o E
`NG ;
* Q Q o c
r
N '0 3
m o
•tc
N A
m
VCD 0
O '
•i -L=O
cm�a
O O
v y Z
HO N �
O C
1- O t O'er~
COD
WCOD
E
umi ' ,o
•N
CLcoo n m�o�
= W m 0 N =
F.c $ a.Z
- -. m
G
z
ip�
U
O
O
W
O
� w
Z CD
CL
R.12rs
O
CWC
' v V
V
m m
O
O � i
O d
CL CCOD
Ma
Q
c
ev
.Q O CD
co
c
ev
cc
IN
O
O
0
O
0
O
12
-7
T- Q T Ci
LIU Lij JJ
Z Z Z o7 Z
0
o 0
iz F-
F— 0 cr cr
0 0 0 0
0 0 m C) CL ()
LU Lil C- Li a -
o" 2 U) z-- (n z (n 7- (1)
M Z T M Z= Z M Z
o o c 0
,P, CP, Lu 00 Uj M UJ (r) Li U", L,
cc, cc a] m ca �n
< < z <
0
0 0
Q 0
C ( 0 r Q)
Li Lij w 0 ul Li L,
o-
IZ
z 2
co (n V) "r ♦ (n
LIJ
C Le 0
c
rl
Date..�....... `�..................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .... .............. `.......................................................
f �U
has permission to perform ............ - ... R.. ..... ... ...................
wiring in the building of ......... .......
................. ...............................................
at .. ....... !.--..:.d%. ... . , North Andover, Mass.
Fee! ............ Lic. No .................
LECTRiCALINSPECTO
Check # n
8 9 J J
11
Commonwealth of Massachusetts Official Use Only
lugDepartment of Fire Services Permit No. 21979
BOARD OF FIRE PREVENTIONREGULATIONS Occupancy and Fee Checked
[Rev. 1/07] /IravP hj._ ,i
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 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 el trical w described below.
Location (Street & Number) /� � �,� ,�j 1r
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit? Yes
Purpose of Building
Ezisting Service Amps / Volts
New Service Amps_ Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Telephone No.
No ❑ (Check Appropriate Boz)
Utility Authorization No.
Overhead ❑ Undgrd ❑
Overhead ❑ Undgrd ❑
No. of Meters
No, of Meters
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 Z BOND ❑ . OTHER ❑ (Specify:)
I certify; under the pains an�altiese operju that informa ' n on this application is true and complete
FIRM NAME: l O 1v
Licensee: 1% ` LIC. NO.:
Signature LIC. NO.:
(Ifapplicable, a er "exe t e li ense n-1�7w
e li .)
Address: �� s. TeL No.: % 7
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: t. L cl. 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 El owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE. $ JA3 °"'
�Y
44
.; w
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Nl"ashington Street
Boston, MA 02111
V j www »urssgov/dia .
Workers' Compensation Insitrance Affidavit: Builders/Contractors/Electricians/Plumbers
Name
Address:
440 -f-
City/State/Zip:
pen po l cy Information.
hone #:- Ale—
Are you an employer? Check.the appropriate box:
t�(I am a employer with
4. El am a general contractor and I
Type of project (required):
employees (full and/or part-time).*
2. ❑ I am a:sole proprietor or partner-
have tired the sub -contractors
listed on the attached sheet. I
6• ❑ New construction
7. Remodeling
ship and have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. [1 We are a corporation and its
9. Building addition
required.)10.
required.)
3. ❑ 1 am a homeowner doing
officers have exercised their
❑ Electrical repairs or additions
all work
myself. [No•workers' comp.
insurance
right of ekemption per MOL
c. 1.52; § 1(4), and we have no
I I.❑ Plumbing repairs or additions
12. Roof
❑ repairs
r uired t
eq ].
.employees. [No workers'
1317met
comp. insurance required.]
'Any applicant that checks bo)e# l must also fill out the section below showing their wsatron
t orkers' com '
i
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 musrattached an additional sheet showing the name of the sub -contractors and their workers' comp. policy infotmadoa.
information.
I ant an employer that is.protnding:workers' compensation ton insurance for my employees: th
Below is e policy and joh site
Insurance Company Name:
Policy # or Self -ins. Lie. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the s an aloes of perjury that the information provided above is true and coned
5i tore: 0
Date: C
Phone #:
ficial 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 conducting authority."
Applicants
Please fill out the workers' compensation• affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage.. Also be sure to sign and date the of idavit. The affidavit should
he returned to the city or town that the application for then 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 numberlisted below. Self-insured companies should enter their
self-insurance license number on the appropriate tine.
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-curmt
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 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 clog license or permit to bum leaves etc.) said perm 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. 4
The Commonwealth of Massachusetts
Department of industrial Accidents
Office of Investigations
600 Washington Street
Boston, IIIA 02111
Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia