HomeMy WebLinkAboutMiscellaneous - 142 BERKELEY ROAD 4/30/2018 1426ERKELEYROAD ��,�--�
210/047.0-0083-0000.0
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Date......
Dat .....
NortrM
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
HU
This certifies that ......... ............M46.0ytws.....................
... ... .... .. ... .............
has permission to perform ............. . ... .................................
wiring in the building of.........daxs:l'.Atia .......................................
qz r3 2
at.....t...................... ...........C..............North Andover,Mass.
Fee..... Lic.No...3� AS. .............. . . .....
ELECTRICAL INSPECTOR
-�Check # f,
10689
C onunonwealth oB/rla66a111tsse14 Official Use Only
r c� Permit No.It 1
aUePartinent o��ire�ervice9
BOARD OF FIRE PREVENTION REGULATIONS Occupancy
and Fee Checked
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 M INK OR TYPE ALL RVF RMATION) Date:d y X01
City or Town of: �1Dd To the Inspector of Wires:
By this application the undersigned gives notice o his or her intention to perform the electrical work described below.
Location(Street&Number) � . >- v
Owner or Tenant L ,e Telephone No. ,50,y 7,21< 0B67
Owner's Address
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building/ ,jf L LM,/ ' Utility Authorization No.
Existing Servicq jQQ Amps 01,j:gj 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:
i
Completion o the ollowin table may be waived by the Ins ctor of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans o.of ota
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators K-VA
No.of Luminaires Swimming Pool Above ❑ n- ❑ o.of Emergency ughting
d. grnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners o.of Def-ftinn an
Initiatin Devices
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
No.of Waste Disposers Heat Pum Namber ons KW No.o Self-Contained
Totals Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
No.of Dryers Heating Appliances KR, Security ystems:
X.
No.of Devices or Equivalent
No.of Water KW No.o o.o Data Wiring:
Heaters Signs Ballasts
No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wirin
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 pains and penalties of perjury,that the information is application is true and complete. �y
FIRM NAME: c�N r �
LIC.N0.:, ¢
Licensee: Signature LIC.NO.;9 �
(If applicable,a er"exempt' in the license number line.) Bus.Tel.
Address: Alt.Tel.No.;
*Per M.G.L.c. 147,s.57-61,security 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 Elowner's
Owner/Agent PERMIT FEE:$
Signature Telephone No.
,.p
�. 3� 2- 1 �
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):—z4j(/, _-d-/N4//,,S
Address:
City/State/Zip: Phone#: 5: Z?6�GG�
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
2,0 employees(full and/or part-time).* have hired the sub-contractors
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. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.[:1 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. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.[No workers' 13.❑Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
A'Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew 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 insurance for my employees. Below is the policy and job site
information. ��
Insurance Company Name:/ � /fir`
. Policy#or Self-ins.Lie.#: fExpiration Date:
Job Site Address:J� (� City/State/Z'
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$1,500.00and/ 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 a a' st the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the D or insurance coverage verification.
1 do hereby er fy er the pains and penalties of perjury that the information provided ab ee is tr e,
t . and correct.
Si atur . Da " �G)
Phone#. ,
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 j oint 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-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 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. C
Please be sure to fill in the permittlicense 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
Date. .��- .... ..
NORTH
Of ��i° ,s 1'YO
o= ° �p TOWN OF NORTH ANDOVER
• - PERMIT FOR GAS INSTALLATION
'y SACMUSEtt
This certifies that . P.�`. . . lrS . . . . . . . .. . .
�--
has permission for gas installation . . . .
in the buildings of . . . . . .. . . . . . . . . . . . . . ;
at . .�, . . r. e A
NoFee.XC�. Lic. NoAS INSPECTOR
Check#
8070
` MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town:-A), Ar,rJ� — MA. Date: e Io 2 2d i Z Permit#
Building Location: f�Z '1C l c7 Owners Name:
Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential
New: ❑ Alteration: ❑ Renovation:Com]" Replacement:❑ Plans Submitted: Yes No❑
FIXTURES
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to z F. O O LLJ J >- Z co 0 W re
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o Oa 4 0 FW- > > > � O
SUB BSMT.
BASEMENT
1 FLOOR
2 FLOOR
3 FLOOR
4 FLOOR
9m FLOOR
6 FLOOR
7 FLOOR
8 FLOOR
70cccorporation
Installing Company Name:MA&#j1IPL k One Only Certificate#
; " ,.2 .
32G C
Address: 3 I �- City/Town: State: jlt44
❑Partnership
Business Tel: L'ii0 3 Fax: ?oY— /So y
" ❑Firm/Company
Name of Licensed Plumber/Gas Fitter: /{INSURANCE COVERAGE:
COVERAGE:
I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes to❑
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy [4'� Other type of indemnity ❑ 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
Signature of Owner or Owner's Agent Owner El Agent E]
By checking this box❑;I 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 my Knowledge and that all plumbing work and installations performed underthe permit issued for this application will be in
compliance with all Pertinent provisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
T p fLicense:
By Plumb
Title / ?� ❑G itter Signature fed Plumber/Gas Fitter
aster )/
Cityfrown ❑Journeyman License Number�7a
APPROVED OFFICE USE ONLY ❑ LP Installer
rf .
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
..600 Washington Street
Boston, 11L4 02111
ovldia
Workers' Compensation Insurance Affidavit:guilders/Con
A Iicant Information - tractors/Electricians/Plumbers
Please Print Leeffity
Name(Business/Organizafion/Individual): + f . SIS
- - Address: 3 S—
City/State/Zip:�//le _
Phone
FEII
mployer?Check the appropriate boa:
mployer with y 4. Fed
oject(required);'
❑ I am a general contractor and I
es(full and/or part-time).V have hired the sub-contractors construction
ole proprietor or partner- listed on the attached sheet odeling
slop and have no employees These sub:contractors have
working for me in any cap acity, workers'comp.insurance. olition
[No workers'comp.insurance 5. ❑ We are a corporation and its ding additionrequired.] officers have exercised their trical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL bing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have noinsurance required.]t employees. [No workers' f repairs
comp.insurance required.) 13.0 Other
*P.ny aB3licR=1 that checks bos=1 must also fill out the section bet t ., .,. .„e; _ _
T Homeowners who submit this affidavit indicating they are doing all work and them hireutside contractors mrdon ust submhey information.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 an employer that is providing workers'
information, compensation insurance for my employees. Below is the policy and job site
Insurance Company Name:
Policy#or Self-ins.Lie,
Expiration Date: RZ
Y
Job Site Address: �cy
Attach a copy of the workers'compensationeclaration page(showing the policy number and expiration da
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.
I do hereby certify under the ains and penalties of perjurlr that the information provided above is true and correct
Si ature: C ,
Phone#:
Official use only. Do not write in this area,to be completed by city or town offciaL
City or Town: PermitlLicense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector :5P1:um:bin_-:1nspector
6.Other
Contact Person:
_.. Phone#:
r
�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 bean 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=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 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
b to d to the city or town fbat the app lies-=on for the per,.aii o?license is being requee—!4 net the Department of
�a r��ie•. s� a s
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 fine.
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 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£ndustrial Accidents
Office of Investig'ations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-8.77 MASSAFE
Revised 5-26-05 Fax#617-72.7-7749
www.Fmss..gov/dia
i .
I`
Location 14Z
No. 155 Date 's
9
of NORM h TOWN OF NORTH ANDOVER
•,..° ,•�
} Certificate of Occupancy $
Building/Frame Permit Fee $
a�emu sE
s Foundation Permit Fee $
s
Other Permit Fee $
TOTAL $ 47�
r
Check # '2
j1 Building Inspector