HomeMy WebLinkAboutMiscellaneous - 1401 GREAT POND ROAD 4/30/2018 (15) l40
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
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This certifies that ................. �. 1� .... .T...................
has permission to perform .. ff .. s .l.4T ..... yl� .�7..........
wiring in the building of...... U.v ...l.: �?�t�...... f!'.!
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at...�.. .....�. �., ... .........�.�. ..,�......... ,North Andover,Mass.
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Fee..-......... Lic.No ....$:......... . .. c... .. � ...........
ELECTRICAL I;S R
Check #
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Commonwea6tl of/i'/adbac4udett6 Official Use Only
F c� Permit No. t)6C 2
2epartment of gire Serviced
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [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 CMR!2.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:
City or Town of: /I/. 19 A (VOP'-fA To the Inspector of Wires:
By this application the undersigned gives notice of his or,her intention to perforin the electrical work described below.
Location(Street&Number) /11a/ axy 1201
Owner or Tenant7—,/ P" 1.4 —Jr4� CSN t r5� Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building 1 joie/ -I 9 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: r- li ec e !-1 4 eryl; nr-,--j
Completion othe ollowin table may be waived by the Inspectorof Wires.
FNo.
f Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total
Transformers KVA
f Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency ig�— -ng
raid. rnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches - No.of Gas Burners No.o Detection and
11 Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alertin Devices
Tons g
No.of Waste Disposers Heat Pump ..,umber, ....ons ..-.., o.o e - ontame
Totals: "'""' Detection/Alertin Devices
No.of Dishwashers . Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliancesxw Security Systems:
No.of Devices or Equivalent
No. of Heaters KW ater No.of No.o Data Wiring:
Signs Ballasts No.of Devices or Equivalent
No. Hydromassage Bathtubs No.of Motors Total HP Telecom municahons Wiring:
No.of Devices or E uivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of If I Work: 2pp,p'O (When required by municipal policy.)
Work to Start: 'O Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE C V E: 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 c,�overa is in force,and has exhibited proof of same to the penmit issuing office.
CHECK ONE: INSURANCE L�BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties ofperjury,thafthe information on this G—eapp7icatrai is true and complete.FIRM NAME: pl� _ , LIC.NO.: /SSS
Licensee: Signature -772 LIC.NO.:
(If applicable, eer "exem t"in th license number line.) Bus.Tel.No.: 9��' 7 �'/,�/2
Address: 14 �ak�� �t/�jP/�� sT ,J�,H�tK� p/9�2 Alt.Tel.No.:9'�"'P/S'= J-/9P
*Per M.G.L. c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: 1 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 air the(check one)❑owner ❑owner's a ent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
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Date� .. .. .?..
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NORTp
TOWN OF NORTH ANDOVER
' PERMIT FOR WIRING
This certifies that ........ � �
........................................................
has permission to perform
wiring in the building of:...... ".: !:�
at................................................................................ ... ,North Andover,Mass.
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Fee....` ............ Lic.No.1f'21-x.-e................ .. ........ .......... .....
LECTRICALINSPE A,
1 Check #
8 , JJ
Commonwealth oMassachusetts
f 7Occupancy
fficial Use Only
Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Fee Checked
[Rev. 1/07] (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WOR
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PMT WINKOR TYPE ALL INFORMATION) Date: -S'— 14 — b n
City or Town of. NORTH ANDOVER
By this application the undersigned To the Inspector of Wires:
gn gives notice of his or her intention to perform the electrical work described below.
rea� oh;
Location(Street&Number) Iy0 � 9
19p
Owner or Tenant Mgl'wv- or, .
Owner's Address S,
Telephone No. �j`1$ sc- o jTq))
Is this permit in conjunction with a building permit?
Purpose of Building �s��r,.�e Yes No ❑ (Check Appropriate Box)
Utility Authorization No.
Existing Service Amps ----L—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:
Com letion of the followin table may be waived by the Inspector of Wires.
No.of Recessed Luminaires 1� No.of CeiL.-Susp.(Paddle)Fans No.of Total
No.of Luminaire Outlets No.of Hot Tubs Transformers KVA
Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- o.o mergency ig g
d. rnd. Batte Units
No.of Receptacle Outlets I� No.of on Burners FIRE ALARMS No.of Zones
�( No.of Switches No.of Gas Burners No.of Detection and
Initiatin Devices
No.of Ranges No.of Air Cond. Total
Tons No.of Alerting and
No.of Waste Disposers Heat PSP Number .ons KW No.of Self-Contained
Totals: Detect3on/Alertin Devices
FNo.
Dishwashers Space/Area Heating KW LOCal❑ Municipal
Connection ❑ Other
w Dryers Heating Appliances , Security Systems:*
Water No.of No.of Devices or Equivalent
Heaters KW Si s Ballasts Data Wiring:
No.Hydromassage Bathtubs No.of Devices or E uivalent
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 of Electrical Work: !I,�-Ob (When required by municipal policy.)
Work to Start: S-- 19-0-9 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 El (Specify:)
P ify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: c b%o%}c L
Licensee: �, �, �, LIC.NO.:
r" e` Signature _
(If applicable, enter "exempt"in the license number line.) LIC.NO.: a 15- t3
Address: Bus.Tel.No.:Cci"13 -cs- I%q l
*Per M.G.L c. 147,s. 57-61,security work requires D „ „ Alt.Tel.No.:
epartment of Public Safety S License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the Iiability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement I am the(check one) ownEl owner's agent
er
Owner/Agent /��---
Signature Telephone No. 28 '1�'y� PERMIT FEE: $
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4C N The Commonwealth of Massachusetts
j 11 Department of Industrial Accidents
Office of Investigations
iiiisl rt 600 fd�ashington Street
Boston, MA 02111
t s www.mass govIdta
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anrpli cant Information Please Print Leembly
Name (Business/Organization/Individual): Hd�hry
Address: 1961
City/State/Zip:_ Ar�o�r,., O I$ys Phone #: .
Are you an employer?Check.tlte appropriate b M
1.❑ I am a employer with 4, Type of Project(required):
❑ I am a general contractor end I
employees(Ml and/or art-time)
p .* have hired the sub-contractors 6• [1New construction
2�0 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 mei' any capacity, workers' comp.insurance.
[No workers'com . insurance 5. 9• Building addition
p ❑ We are a corporation and its
required.] officers have exercised their i0t Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.. Plumbing repairs or additions
myself.-[No-workers'comp. c. 1.52, §1(4),and we have no 12. Roof
insurance required.]t employees. ❑ repairs
[No workers' I3.Q.Other
comp. insurance required.]
•Any applicam that checks bosC#l must also fill out the section below showing their workers''compensation policy information•
t Homeowners who submit this affidavit indicating they ars 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 work='comp,policy information.
I am an employer that is providing:workers'compensation
information, snsurance f or my employees: Below is the policy and job 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 e. 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 DTA for insurance coverage verification.
I do hereby certify under the pains and enables of perjury that the information provided above is true and correct
Signature: Date. CX
Phone 9:
Ofj`fcial use only. Do not write in this area,to he 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 bmstee 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 locai 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 LLC or LLP does have r
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 numberlisted below. Self-insured companies should enter their
self insurance license number on the'appropriata 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 ofthe 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.# 617-727-4900 ext 406 or 1-8.77-MASSAFE
Revised 5-26r05 Fax#617-727-7744
www.mass.Dov/dia