Loading...
HomeMy WebLinkAboutMiscellaneous - 13 WALKER ROAD 4/30/2018 (5)Date ��1. �� /� Z, This certifies that. .!-.YR N—cA.Z? ... 0. lr2l 4-. e.r ............. has permission to perform 4-A -6-k;,J 4-? - �7 ...... wiring in the building of .... LQ11 ........................... at . ........... h1orth Andover, Ma Fee 90 Lic. N2(�).o6 .. if EL CTRICAL INSPECT R Cheek# 267 11'i49 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official /Use Only Permit No. I ` Vq Occupancy and Fee Checked [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 C12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: p /� 71Z City or Town of: NORTH ANDOVER To the Inspector of ices: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) '1.3 WA'L 0' Ab. 00 f S IW*00 Co COA)b6S Owner or Tenant bAv6 �—d Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes R No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service 44M Amps , / 3-0%D Volts New Service Amps . Number of Feeders and Ampacity Location and Nature of Proposed ,N Two C Volts Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ Work: RE LCcAT IC G�kl�CfiirlP', S/f�o) /kdb cfcr CoA rn.6). No. of Meters No. of Meters fid,© /S&J- ZACN Com letion of the following table maybe 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 Swimming Pool Above ❑ In- ❑ rnd. grnd. 0.0Emergency Lighting Battery Units No. of Receptacle Outlets o7, No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches a No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges ` No. of Air Cond. Tons Tot No. of Alerting Devices Heat Pump Number Tons 2 KW No. of Self -Contained Disposers No. of Waste Dis P Totals: .............................. Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal ❑ Other Connection No. of Dryers Y Heating Appliances KW Security Systems:' No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts 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 oJ Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: W i Ll. CA Q_ 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 ams andpenalties o perjury, t t the information on this application is true and complete. FIRM NAME: R4nt G i's W, M r c1b K, <A LIC. NO.. Licensee: S411tc Signatur c LIC. NO.: 3 (If applicable, enter "exempt" in the tce�r sent ber lie Bus. Tel. No.: g Address: o`� �.✓�� 7d W 1 c I�U00 0474 Alt. Tel. No.-T78'8'0e W *Per M.G.L c. 147, s. 57-61, security work requires Depaftment 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 [PERMIT FEE: $ Signature Telephone No. i wJ ' d . % 1 r «..�(iJJu.IPJtl..rf.J.A-1.'U�t�(�'�t��jir�-�LjY�1�Y1�Jy.J.�l,�,'l.�(y®�y��Y. /-� �1l..Llil3CJ4.V�JL�.v.L ®J�•..l.i r .Vi A1J�tL.L.Ci-q.�.r.L�,fl.l.�.RF7����V'�" i .. `.. y .. '� • "`� lispeetore cozmmexts: ' ,j +_ ter t U :•i '• w ✓ .> /�, . (XuspWoxsti Wndvablo difals) date 3�'assec� �`ai�et�--r � � Xte�ns�eettoxtxet�uixe� (��0.00)-• j. � ' �t5�ecta ' co extts: (JCns�ieetoxs' zgnatuxe muffals) Slate 'asse�� Z � �'afIet�—• L � �te�xns� eetzo� xe�uixe� ���O.UO) N j � asioectoxs' com�e�.ts: (tnspectoxs',�ignaiuxe�+�o �izitaTs} ]ate . ' ��EC�o�—�EXa.'► INCE: ;�ectaxs9 eopameptfs: 'w H'A: �e znspeetzo: (Xus�ectoxs' �iguatuxe � 7ao inzt[axs) ea•--F+azled'-�- 'atens�peettoxt eCto:rs' COP17CC1�17tS: .)JO Data n-R'PAV—.q Q ITV AM AM,A ��R��7�"P�i'�!A'iP�➢a�1�7d1�iT r 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 �p Please Print Legibly Name (Business/Organization/Individual):pJC/ Address City/State/Zip: F,,// V� `/� 00 6 Phone #: 6 /— e5l' ��-7 �'4� �C�� 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. P am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. �modeling 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 41 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. 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 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. #: Job Site Address: Expiration Date: 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 3f 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 hereb certi under thepins and penaltiA of pgkjury that the information provided above is t1tte and correct. I- 41ta � 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 #: -a 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. 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 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 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia -1 N° 9679 Date.!l '�oljZ TOWN OF NORTH ANDOVER < o PERMIT FOR PLUMBING This certifies that has permission to perform ..................... plumbing in the buildings of�Lk10—............. Aat ....,.? ..1�1 �L-�? t'" , . ...... . �p ,n ,North Andover, Mass. Fee�-"J. -.... Lic. No.7a .. 'M.0 .......................... PLUMBING INSPECTOR Check # l71 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer v j MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK g CITY Jp �vP�✓ �I MA DATE C-79 � PERMIT # 14 JOBSITE ADDRESS / w (C S' j OWNER'S NAMEJV P OWNER ADDRESS x jk TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL D RESIDENTIAL(2' PRINT CLEARLY NEW: D{ RENOVATION: E2'-' REPLACEMENT: D PLANS SUBMITTED: YES EQ NOD FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DE ICATED GAS/OIL/SAND SYSTEM ! -,.._ JI DEDICATED GREASE SYSTEM_1= ..__......f f --...__ ...._. I .__...._.i f ----._._.1 � _......_ I ._._.__.._.( ^_.{ ______{ _ _f L___J DEDICATED GRAY WATER SYSTEM€ DEDICATED WATER RECYCLE SYSTEM DISHWASHER .___._.__J DRINKING FOUNTAIN---f---..__t _.. FOOD DISPOSER € ._.._.._J __-_-- ---.___E. (.___...--.....__! ._..__._f L ---ill FLOOR/AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK € l _( .__ _{ _j ___.__f _.-_J .__._._._f —I ___._..i ..__._{ ._.-_€ TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER I J1 INSURANCE COVERAGE: have a current liab, ility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NOD IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY DI OTHER TYPE OF INDEMNITY Ej BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT _! SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of y knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertfn t pro ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME h h Vrl LICENSE # SIGNATURE MP{ JP CORPORATIOND # -1PARTNERSHIP # s LLC _...i COMPANY NAME �'I r C'�tc��b } ADDRESS I CITY I STATE `iv( ZIP C� TEL _$ — �— I CELL 2a 3� EMAIL FAX ��-S - -- --..f� W H °z z o w � � N or z y O H W p W O ® a W w a ® w d a o a � W a � U J a a a Ln t1i s w a a H z ti 0 U W P, a c�7 O 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 Ledbly Name (Business/organization/Individual): 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 and have no employees These sub -contractors have working for mein any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] f employees. [No workers' comp. insurance reciuired.l 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. kContractors 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: ?olicy # or Self -ins. Lic. #: Expiration Date: `ob Site Address: City/State/Zip: kttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 T up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify under the pain and penalties 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: 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. 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 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 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia