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HomeMy WebLinkAboutMiscellaneous - 14 SECOND STREET 4/30/2018 14 SECOND STREET / 210/03/03=0000.0 I Date.... 1�41 �'�."°omaTOWN OF NORTH ANDOVER PERMIT FOR WIRING SS C" S oo This certifies that .......��T�w.......... has permission to perform ........ ...... .....Z.........C�.;Ys-r) ............ ... wiring in the building of...1W.7-k u�. .................................. at... ,rn,,t Andover, ................................. ..... North Andovei,Mass. 00 Fee.-51��........ Lic.No..�V. ... ...... c3 LECTRIC NsPE R I Check It 10545 Commonwealth of Massachusetts Official Use Only a Department of Fire Services Permit No. (gib L-f,;7 BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. 1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC) 527 MR 12.00 (PLEASE PRINT INIAW OR TYPE ALL INFORMATION) Date: 12 l i g 2©t City or Town of: NORTH ANDOVER To the Inspector of By this application the undersigned gives notice of his or her intention to perform the electrical worklescribed below. Location(Street&Number) Owner or Tenant Telephone No. of - _U1� Owner's Address 2 e� - c Is this permit in conjunction with a building permit? Yes ❑ No a � (Check Appropriate Box) Purpose of Building SI '1f eCAt �`cZ Utility Authorization No. Existing Service UC Amps [2a / 2- 0Volts Overhead Und rd ( g ❑ No.of Meters New Service t6O Amps 120 /2 o Volts Overhead Und rd g ❑ No.of Meters Number of Feeders and Ampacity •• Location and Nature of Proposed.Electrical Work: `�rz l��� CQ�(�Ji�e o(�ry j✓15fi� � e 4 v k_41, Y-6 61 i QD e 5 Com letion of the followin table may be waived by the Ins ector o Wires. No.of Recessed Luminaires No.of CeU. 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- o. o mergency ig ng d. r- ❑ Batte Units No.of Receptacle Outlets No.of Ola Burners BI'` 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 Number .Tons.. KW No.of Self-Contained Totals: Detection/Alertin Devices - No.of Dishwashers Space/Area Healing KW Local❑ Municipal A Connection El Other No.of Dryers Heating Appliances KW Security Systems: No.of Water No.of No,of Devices or Equivalent Heaters KW Si s BBallal of Data Wiring: Ballasts . No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value o .Electrical Work: Work to Start: �'Z f�1 Zc ` (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 coves is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 2 BOND ❑ OTHER ❑ (Specify:) I certify,under the aims and penalties of perjury, that the information on this application is true and complete- FIRM NAMe *Y ' a( Q r`o LIC.NO.: 2 oMy -A Licensee: Q Vlih0.. NGe e��Gvwn Signator LIC.NO.: 1 (If applicable, a ter"exempt"in the license number line. 1 6h g - Address: {{,�>,� �rQ^ �� Bus.Tel.No.:%l-6L)I6 *Per M.G.L c. 147,s. 57-61 security work requires Department Public Safety'S"License: Alt L cI.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. PERMIT FEE. $ ! i The Commonwealth of Massachusetts ir k- 1 Department of Industrial Accidents ' Office of Investigations s;�t 600 Washington Street Boston, MA 02111 {' www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organizadon/lndividual): /� � o p • 1.4 Address: City/State/Zip: � u r pm , . tn� 019D k Phone AE�yo p anemployer?Check the appropriate box:am a employer with 4. ElI am a general contractor and I Type of prefect(required): 6 employees(full and/or part-time).* have hired the sub-contractors ❑New construction 2.❑ 1 am a.sole proprietor or partner_ listed on the attached sheet.x 7. ❑ Remodeling ship and.have no employees These sub-contractors have 8. ❑Demoiiti.on working for me.in any capacity. workers, comp. insurance. [No workers'comp.insurance 5. p• ElBuilding addition p ❑ We are a corporation and its required.] ,-, _,,� red.] officers have exercised their 10. LXI—ectrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 1.0 Plumbing repairs or additions t myself, [No-workers'comp, c. 1.52, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' comp. insurance required_] 13.0 Other *Any applicant that checks boz#l must also fiil out the section below showing their workers'compensation policy information, t Homeowners who submit this affidavit indicating they are doing all work and then hue 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'c--p.p^licy i ii3,;,aon. lam an employer that is providing:workers'compensation isuanefor a toYee& Belowistheinformation. policy and ob site Insurance Company Name: Policy#or Self-ins.Lie.#: _�,� j_p Expiration Date: 1� 2 o f 2 Job Site Address:_t`i d s� f ic, City/State/Zip: r. a yr V Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). 1 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 ins ce coverage verification. I da here y n the p and pe of perjury that the information provided abo a is true and correct Signature: 2 �� 'Zoe, Date: Phone#: -3 ---b 1 kJ O fficialonly. Do not write in this area,to be completed by city or town officio[ n: Permit/Licensehority(circle one): Health 2. Building Department 3.City/Town Cierli 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 or to construct buildings is the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insr rance'covernge required." Additionally, MGL chapter I52,§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 box s 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(L P)with no employees other than the members or partners,are not required to carry workers' compensation insurance. if in LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted toe Department of industrial Accidents for confirmation of insurance coverage.. Also'be sure to sign and date tie affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being r6quested,not'the Department of Industrial Accidents. Should you have any questions regarding the law or if you are I required to obtain a workers' compensation policy;please call the Department at the number.listed below. Self-iured 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 hat 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 liumber. In addition,an applicant , that must submit multiple permit/license applications in any given year,need only SL bmit 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 cior town may be provided to the 4 applicant as proof that a valid affidavit is on file for future permits or licenses. A nel8Iv affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to;6 business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to com}Tete this affidavit. The Office of Investigations would like to thank you in advance for your cooperatiol 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 I-8.77-MAS AFE Fax 4 617-727-77451 Revised 5-26-05 VAW,mass,gov/dia W - O=blank) GMMUIt1Ur #� Qf 4&90 t Ugrtto Permit NoMepartment af 11uhik �IIfrtg OccupancBOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 tj Y APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date co `z F6 MW or Town of�QR�Ij. ANT1OY-EI To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) �% `sem �h` S7— Owner 7— Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes ElNo � (Check Appropriate Box) Purpose of Building -AQ Utility Authorization No. Existing Service 30/3 Amps _J o volts Overhead LFJ-, Undgrnd ❑ No. of Meters _ New Service Q_ Amps _/2 j 2-Y()Volts Overhead Undgrnd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work ��� to C.4.2 12�6 Z 0 y 0 !g No. of Transformers Total No. of Lighting Outlets I No. of Hot Tubs KVA e In- No. of Lighting Fixtures I Swimming Puol Above ❑ n- ❑ i Generators KVA gmd. No. of Emergency Lighting No. of Receptacle Outlets I No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones Total No. of Detection and No. of Ranges I No. of Air Cond. tons In-ating Devices Disposals No.of Heat Total Total No. of Dis P I Pumps Tons _ KW No. of Sounding Devices N, of Self Contained No. of Dishwashers I Space/Area Heating KW ;atection/Sounding Devices I � fro. of Dryers I I Leat r; vevice; }!vJ Local ❑ Municipal Connection ether No. of No. of Low Voltage _.�., rh-s'": te. r, g•n,v- .. KW I Signs Ballasts \NirinaNo. Hydro Hydro Massage Tubs No. of Motors Total HP OTHER: ' INSURANC COVERAGE: Pursuant to the requirements of Massachusetts general Laws ^ I have a cent Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES = NO I have submitted valid proof of same to the Office. YES = NO :: If you have checked YES, please indicate the type of coverage by checking the apopopriate box. INSLJlrCE BOND ` OTHER (Please Specify) i � (Expiration Date) Estimated Value of Electrical Work $ t �� Work to Start 155'— Z '96 Inspection Date Requested: Rough Final 1& /r�� �G ` / Signed under t enalties of 7r, v ( FIRM NAME t LIC. NO. I— ��CC Go Licensee Signature LIC. NO. Bus. Tel. No. —� Address S�y� (0��� / '�=— ��= Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Teleohone No. PERMIT FEE S - (Signature of Owner or Agent) x•6565 !T .:/. •��.SQ I rJ Date. LW.c). i d NORT1y TOWN OF NORTH ANDOVER .0j op PERMIT FOR IN ACMUSES + / I ! This certifies that . .!t/ . . . . . has permission forstallation ( ✓1 .,.,,, in the buildi s ofd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee j�.'tr. Lic. No.j�'1.! 40 . . . . . . . . . . . . . . . . . . . . . . . . . . ®97c8INSPECTOR WHITE:Ajdf12YjC+2-`CAN 1Id t. PINK:Treasurer GOLD: File06/ ��d�'� �pI9eP ,