HomeMy WebLinkAboutMiscellaneous - 120 WATER STREET 4/30/2018 (7)i
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Date .....
AORTM
01 4,
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .... .............. .. ............................
has permission to perform ............
wiring in the building of ..V ... W#Tmi. .......
at ............ VJ A7251,� S
.................................................... North Andover, Mass.
ee..................... Lic. No..... ... ................ . .. ....... .......... .......
ELECTRICAL INspEct6it
Check 4 Z-
8839
N
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. FY3 C)
Occupancy and Fee Checked
[Rev. 1/07] (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: _ / d 9
City or Town of: NORTH ANDOVER To the Inspector of Wires: r
By this application the undersigned /giivves,nnotice of his or her intention to perform the electrical work described below.
Location (Street & Number)___,/ u/�L�l J�l� .q
Owner or Tenant
LA -0,a j �
4cl4 Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No
❑ (Check Appropriate Boa)
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:
Completion of the followin table may be waived b the Inspector of Wires.
No. of Recessed Luminaires
le) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
M=B!tLeMunits
Generators KVA
No. of Luminaires
Swimming In-
�
�
o. o mergency ig g
rnd.
Bette Units
No. of Receptacle Outlets
No. of Oil Burners
FIFE 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 Self -Contained
No. of Waste Disposers
Heat Pump
Number.
KW
Totals:
.Tons
Detection/Alertin a, Devices
No. of Dishwashers
Space/Area HeatingKW
Local ❑ Municipal
Other
Connection
No. of Dryers
Heating Appliances ICS'
Security Systems:*
No. of Waterof
KW
No. of No.
No. of Devices or Equivalent
Heaters
Si s Ballasts
Data Wiring:
.
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or E uivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, under the pain andpenal res ofperjury, that the information on this application is true and complete.
FIRM NAME: 1, ft4l 1-7 p LIC. NO.:
Licensee: Signature LIC. NO.:
(If applicable, enter "exempt " in the license number line)
Address: Bus. Tel. No.:
*Per M.G.L c.57-61, security work requires Department of Public Safety "S" License: Alt 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 ❑ owner's agent.
Owner/Agent /�
Signature (�/� Telephone No.SV Jfi d � I PERMIT FEE. $
��.'.,,q�r d �c to �z3-o i ��
I
11
a
The Commonwealth of Massachusetts
Department of Industrial Accidents
•- Office of Investigations
%M 600 Washington Street
Boston, MA 02111
www.tnass.gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Piambers
A>Aplicant Information Please Print Legibly
Nate (Business/Orgmizadon/individual); T re J
Address:
Ila /t%
City/State/Zip: k {0 �F0 Pbane #:. Q
Are you an employer? Check -the appropriate box:
Type of project (requires():
1. [] I aro a employer with 4, ❑ l am a general contractor and I
employees (full and/or pari -time).* have hired the sub -contractors 6. ❑'New construction
2.X I am a.sole proprietor or partner_ listed on the attached sheet. x 7• Remodeling
ship and have no employees These suit -contractors have 8. ❑Demolition
working for me .in any capacity, workers' comp. insurance. g, ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10•❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work right of exemption per MGL 11 -ED Plumbing repairs or additions
myself [No•workers' comp, c, 1.52, § 1(4), and we have no 12. Roof
insurance required.] t ❑ repairs
9 ] employees. [No workers'
comp. insurance required.] 13.❑ _Other
'Any applicant that checks bort # l 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.
;Contractor; that check this box must attached an additional shcz• showing the name of the sub -contractors and their workers' comp. policy information.
I ant an employer that is providing workers' compensation insurance for nF employees.• Below is the policy and job site
information.
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 WORT{ 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 and the pains and penalti of perjury that the information provided above is true and correct,
Si tore: L Date:
Phone #:
O
fficial use only. Do not write in this area, to be completed by city or town official
ty or Town: Permit/License #
uing Authority (circle one):
Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Other
Contact Person: Phone #:
yt
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, 4 ,
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 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 cordracting 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), addresses) acid 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, nofthe 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. Sei 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 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
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. # 617-72.74900 ext 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia �.,...:
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-1 Date ..................................
_ <ti
TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
,SSACHUS c�
This certifies that g
has permission to performs .. .................ti
wiring in the building of ....I .................................:............�...�.:
at ............................................................A—ELECTRii
,North Andover,,Mass.
Fee . ........ Lic. No�l � ./:_3rp .......ZILINSPiEl
. .... .4IR
r� Check // �f0
882 5.1
N
u
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. Alp?
Occupancy and Fee Checked
[Rev. 1/07] rtPaon �i,"v�
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 LN INK OR TYPE ALL INFORMATION) Date: 0-1 �16 10�1
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 electrical work describe belo .
Location (Street & Number) �0a 1/� ij 9k (Jr v4j ��y4(� describe
Owner or Tenant 1p,&6
Owner's Address /r4f1®l .44
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 N
No ❑ (Check Appropriate Box)
Utility Authorization No.
Overhead ❑ Undgrd ❑
Overhead ❑ Undgrd ❑
No. of Meters
No. of Meters
uezuu 'J ueszrea, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start`,i (? 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 enaltzes of perjury, that the 'formation on this application is true and complete -
FIRM
NAME: �' n LIC. NO.:
Licensee: Signature #19A
(If applicable, enter " empt " in the lie number 1'n �� LIC. NO.:
Address: �' 40� Bus. Tel. No.;
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt L c. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
Orequired by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
wner/Agent
Signature Telephone No. PERMIT FEE.-
Official
EE.
I
v !
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov%dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Nan'ie (Business/organiradon/Individual):
Address: /I- A/
City/State/Zip:
Phone #:.
Are you an employer? Check -the appropriate box:
L�12 am a employer with % 4, ❑ I am a general contractor and I
Type of project (required):
employees (full and/or part-time).*
2.❑ I am.asole proprietor. or partner-
have hired the sub -contractors
listed on the attached sheet. x
6• ❑New construction
7. ❑ Remodeling
ship and have no employees
These suit -contractors have
8. ❑ Demolition
working for mei any capacity,
[No worker;' comp. insurance
workers' comp, insurance.
5. ❑ We are a corporation and its
g, ❑ Building addition
required.)
3. ❑ I am a homeowner doing
officers have exercised their
MGL
10.❑'Electrical repairs or additions
all work
right of exemption per
I I.❑ Plumbing repairs or additions
myself. [No -workers' comp,
c, 1.52, § 1(4), and we have no
12.[] Roof repairs
insurance. required.] t
employees. [No workers'
1317 e7
comp. insurance required..]
rr -7- —..+— vox S, must also nu 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 insurancefor my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Expiration Date: /
Job Site Address:�z� ��T City/State/Zip:�/; �7/0p,
_
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration dai!e).
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 $4500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
/ Ido hereby certify under the orns a nalties of perjury that the information provided above is true and correct
Si tore: p
Phone ##: VII/
=Health2.
only. Do not write in this area, to be completed by city or town official-
n: Permit/License #
hority (circle one):
Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
son: 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 orlto construct buildings in the commonwealth for any
applicant who has not produced acceptable evidenceofcompliance with the insurance 'coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation• affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to cavy 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 confinnation 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 numberlisted below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officiais
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 vvilLbe 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 as a call.
The Department's address, telephone and fax number:
ti ..
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 102111
Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE
Revised 5 -26 -US Fax # 617-727-7749
www.mass.gov/dia
ti