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HomeMy WebLinkAboutMiscellaneous - 140 WATER STREET 4/30/2018Date ... 6 9 ... ................... TOWN OF NORTH ANDOVER ,PERMIT FOR WIRING This certifies that . . . ....................... ........................... has permission to perform ...................................... wiring in the building of ...................................... at ................... ........ North Andover, -Mass. Fee e? -5 ............. Lic. No . ................. ... ............ . LUTO MTRICAL NSPEMTO Check # rn?,QA43 8425 Commonwealth of Massachusetts Elm slow Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 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: i 4 ib 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 electrical work described below. Location (Street & Number) NO�— Owner or Tenant j)cVdyi ,loll Telephone No. Owner's Address ri4r Is this permit in conjunction with a building permit? Yes [9—' No ❑ (Check Appropriate Boz) Purpose of Building � es �t't� 1 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: RVa[Ai a � J F -IM - Com Teti th !l No. of Meters No. of Meters auacn additional detail !f desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 4iU p6 (When required by municipal policy.) Work to Start: -&I%d116 y Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE O 7ERAGE: 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 [5 -'-BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: c LIC. NO.: A61 J Licensee: (rcd FfIlk Signature LIC. NO.: (If applicable, enter ' empt" in the license number line.) Bus. Tel. No.: 9 %k' q i 9 9W,t Address: 6 J Si?%l,.al,5l./ a a /Vail X00 OI l�Gcf Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, sec -unity work requires Department 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 Signature Telephone No. PERMIT FEE: $ Lj on of e fo owin 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 % Swimming Pool Above in- ❑o. o Emergency Lighting rnd: rnd. i Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE E ALARMS No. of Zones No. of Switches No. of .Gas Burners No, of Detection and InitiatinTotal Devices No. of Ranges No. of Air Cond Tons No. of Alerting Devices No. No. of Waste Disposers Heat PSP Number Tons _ KW No. of Self -Contained - No. of Dishwashers �- Detection/Alertina Devices Municipal Space/Area Hea`inf Local ❑ El Other Connection No. of Dryers —1KW Heating Appliac> c KW Security Systems:* No. of Water No. of No. of No. of Devices or E uivalent Heaters KW Signs 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: auacn additional detail !f desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 4iU p6 (When required by municipal policy.) Work to Start: -&I%d116 y Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE O 7ERAGE: 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 [5 -'-BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: c LIC. NO.: A61 J Licensee: (rcd FfIlk Signature LIC. NO.: (If applicable, enter ' empt" in the license number line.) Bus. Tel. No.: 9 %k' q i 9 9W,t Address: 6 J Si?%l,.al,5l./ a a /Vail X00 OI l�Gcf Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, sec -unity work requires Department 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 Signature Telephone No. PERMIT FEE: $ Lj rr , f nr. r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 YVashington Street Boston, MA 02111 I - www_rrzass,gov/dia Workers' Compensation Insurance .Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Leaibiy Name (Business/Organization/individual): P; �% �✓IeC�/�t� Address: 'l City/State/Zip: "VIS MA Q 1� bu Phone #: Are you an employer? Check the appropriate box: I . ®'lam a employer with j 4. El am a general contractor and 1 Type of project (required): employees (full and/or part-time).* have hired the sub -contractors 6• ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 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. ❑ We area corporation and its 9. Building addition required.] officers have exercised. their 10:0 Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.[] Plumbing repairs or additions myself. [No workers' comp. insurance required.] t c. 1.52, § 1(4), and we have no employees. [No workers' 12.[] Roof repairs comp. insurance required.] 13 -El Other -- -•• •- • ••• • ��� •••• amu• ..•_ a -uu umow snowing their workers' compensation poiicy information. I Homeowners who subuiit.tltis affidavit indicatuig Uiey are "7 19 nil wurk Wid then hire outside contractors musi submii.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 i►rsurancc for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -.ins. Lic. #: _0& Expiration Date: 0010 -f Job Site Address.- L q- ym 4- V_ City/State/Zip: jA /U/." 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. 1 do hereby cert4oyj under the pains and penalties of perjury that the information provided above is true and correct D /� Official use only. Do not write in this area, to be completed by city or town official City or Town: PermWLicense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. 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 incensing 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 -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 cant' workers' compensation insurance. If an LLC or LLP does have ._ employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit Theaffidavit 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 aworkers' compensation policy, please call the Department at the nurnber.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/iicense 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 "ail 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 Investigatiions 600 Washington Street Boston, MA 02.111 Tel. 4 617-727-4900. ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax 4 617-727-77449 ww4v.ir1ass.gov/dia h Location No. 13:5-9 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ + Other Permit Fee $ TOTAL $ Check #�� 17825 Buitding.lnspecto TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING filT BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: P7 -a4411- Building Commissioner/I for of Buildings Date oLl.T1Av niTT i1ir.AT1r ..... i... _ 1.1 Property Address: va.v aavi��.-aawaL'a�aa V��1\L`a�OlalrlLfV lilVlCLt�a'L AIsGl\1 ""`""" vivui,J 1.2 Assessors Map and Parcel Map Number Number: Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard RNWred Provide ReqWred Provided Provided —ReqWred 1.7 Water Supply M.G.L.C.40.V54) 1.5. Public ❑ Private 0 zona blood zone Information: Outside Flood Zone 0 1.8 Municipal Sewerage Disposal System: 0 On Site Disposal System ❑ L. .GJ IVI'd 2.1 OwnerA Record -PAX 9 ///� rL/, qlle,e- 1-5 14ame (Print) Address for Service i 2.2 Owner of Record: Name Print Nignamre SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Address for Service: Signature Telephone 3.2 Rettisteltrd Home Contractor Comp Name awewl Addr/ �/�ess 'nz 12 - 7 Not Applicable ❑ License Number ! Ah /, Expiratio Da Not Applicable 0 l� 3�� Registration Number Expiration to s SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION S Description of Proposed Work check alta cable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other. ❑ Specify t Brief Description of Proposed Work: /�n A D — I CF.CTInN 6 - RSTIMATF.D CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Com ted by permit applicant OFFICIAL USE ONLY 1. Building �© C (a) Building Permit Fee Multiplier SIZE 2, , Electrical (b) Estimated Total Cost of Construction , Plumbing Building Permit fee (a) X (b) r) UIQ5 / 4 Mechanical HVAC Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief � Print Si ature of Owner/Ag4nt 7� Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST 2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION. THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE - x w ch o H a a a -8 o w -§ o w t r- x U r X. a wo' w a a r. Ca U W o w a � w w A z w cA �o cn o cn 4, YWNW- C, d0 ■ Z f; O Q y it GOQ��,Q' 0 z lm� of Ai MA 45 45 N zip N c ca co m cc cm m O CM c m 0 Z 0 g cm F. L Z a O y cmCD cm C I � C 0 ME m m � 0 � m IS 0 cc oa cma o c cc .c 'v c Z m C..3 co � C cc C. CO2 ca LLI II�w Y/ U) W W oc W N Propool _ CS # 022680 HIC# 103358 A. J Walsh & Sons 55 Pleasant Street North Andover, MA 01845 Proposal Submitted To: # of Job Name // . I Job # II Address t1jq / 41 /��� � I Job Location 978-688-6737 or 1-866-AJWALSH Date , _ 1 / I Date of Plans Phone # / /I Fax # I / I Architect We propose hereby to furnish material and labor — complete in accordance with the above specificatio , s for the sum of: $ ��� Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs will be Respectfully executed only upon written order, and will become an extra charge over and submitted above the estimate. All agreements contingent upon strikes, accidents, or delays ,J�' beyond our control. Note — this proposal may be withdrawn by us if not accepted wifhin days. 01cceptance of propont _ G, The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. 6 Date of Acceptance Signature NC3819 MADE IN USA t The Commonwealth of Massachusetts Department oflndustrial Accidents ' _ Office of lnlrestigations (.\�--;� 600 Washington Street, 7'hFloor Boston, Mass. 02111 Workers' Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors R _....,..... M address:,(/ `/y "'` / "1,rJ� city /)�� ./l/,dUf�'�' state % zip ®�7 phone # H I am a homeowner performing all work myself. Project Type: ❑ New Construction ❑Remodel ❑ I am a sole proprietor and have no one working in any capacity ❑ Building Addition ❑ I am an employer providing, /workers' compensation for my employees working on this fob. � Y company name:. j„'� address -e/�.i�%%i� % city /& s-��/ �� phone # insurance eot'/ ohc # '! t„4 .' a s1 h° 4 �i .�sle.a', trCd�� atY �1�: aTi afs x '+lY'- XMI, t x(_i�a tit'L I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation polices: compaim.name: address city: uhoiie# 4. insurance.co ohc # ” - -ni ii•F1S ..ac12�9�vs�CEn4'itiad�Yr+i FtiF .�C 4t�i7y Pl j h vYSyy? a G 1 fikbAa'1 u'vYRt, company name: - - .. . address city: phone # insurance co ohc # ttah add�lio alis a tt r �e'essp"' +i_ i -?I..#arw .n�l�M, " . 5.....�t-?+�.;.3-: ai ure to secure coverage as required under Section 25A of MGL l52 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/?':i or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 7 do hereby official use only do not write in this area to be completed by city or town official city or town: ❑ check if immediate response is required contact person: (revised Sept. 2003) is true and permit/bcense # ❑Building Department ❑Licensing Board ❑Selectmen's Office ❑Health Department phone #; ❑Other 7 Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", 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. Howeventhe 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 section 25 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, 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. si NIP i F ,1res �tE: Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits 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. r� r Er ri"a ar rwr, irJat; ..r ��y. x� t{t,.� ir. d�6.*t =� �. '' i ,. `�- �,�#t,�� 7f "'•. ��.- � 4i. vs City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. J oaxati qr'-c` r} .!` _"f..;:',.4 �n k:.,?. i✓,.>E✓,t .�.. 7�,. ..im 1.:„� le; -.d. ,}t ._5`t�Y,f„A'.;ss���i«r: The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of. Industrial Accidents Office of Investigations 600 Washington Street,7t' Floor Boston, Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406 North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of (Location of Facility) Signature 0 Permit Applicsint Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector ` ^ ` � ^ DING REGULATIONS TION SUPERVISOR 22680 Tr. no: 71.0 commissioner