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Home My WebLink AboutMiscellaneous - 15 MILLPOND 4/30/2018 15 MILLPOND --- - - -- -- - - - 210/095.=00.0 ,� i i �� Date......Z.�....J.. ......... .'? NopTN TOWN OF NORTH ANDOVER to ' PERMIT FOR WIRING CHUS�t r This certifies that ............: ,..... has permission to perform ../c z.;f * ti- ...,./�.. v " .. wiring in the building of.............. Arl '`'..................... at / . ... ( .... K r. '.•..................................1 .1...,North Andover,Mass. F ........ ................Lic.No./6tl��. 'ELECTRICAL INSPECTOR Check# J3 Z 2 1141 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. �� Yf 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(NEC),527 CMR 12.00 (PLEASE PRINTWINK OR TITEALL RWORMATIOA9 Date: /Z — 13 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to pe.Iform the electrical work described below. Location(Street&Number) , / Owner or Tenant e Gc , Telephone No. $7d' X�? `�3�F I Owner's Address -� L Is this permit in conjunction wit building permit? Yes ❑ No Check Appropriate Box)) Purpose of Building (0- 1"K d 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: s f Completion of thefollowing 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.of Emergency Ligfiting rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE 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 No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: ""' _ '"' ""'""""""""""""""".......... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers 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 Ea 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: 2 —12- -1_? 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 ' ee,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) I certify,tinder the pains and penalties f. 4iry,that the information on this application is true and complete. FIRM NAME: . a 1,—f // - /2 le �— IC.NO.: Licensee: Xc,, a It Signature LIC.NO.• r (Ifapplicable,a er "exempt'pin t ie license number line.) Bus.Tel.No.- Address: Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Departmentl6f 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. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entityshall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: t Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass r?] Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com 7 The Commonwealth of Massachusetts Department of IndustrialAccidents 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 Legibly Name (Business/Organization/individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.El I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.E] I am a sole proprietor or partner- listed on the attached sheet. $ E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers'comp.insurance. 9 y p ty ❑Building addition workers' comp.insurance 5. El are a corporation and its [No required.] officers have exercised their 10.El 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 12.0 Roof repairs insurance required.]f 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. Homeowners who submit this affidavit indicating they are 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 workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and fob site information. isurance Company Name: olicy#or-Self--ins.Lic.#: Expiration Date: 3b Site Address: City/State/Zip: .ttach 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 ne 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 C up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is trite and correct ignature: Date: hone#: 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 t 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 f 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 of 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 .evised 5-26-05 Fax#617-727-7749 www mace (M-171din 4061 /�� Date......?. kGRTM ..S TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING Io C14US .. ... .../ ............... This certifies that .......................... ...... .............. has permission to perform ........... ............................... wiring in the building of........ at................ .... ..............—,................. ...... .... North Andover,MO. Fee..`TJ No../3..3.36........ . ........... ... ... ELECTRICAL PEC .. L...........TOR Check # -7 ` Commonwealth of Massachusettso Permit No. al Use Only Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/991 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code( ,527 CPR 12.00 (PLEASE PRINT IN INK OR TYPE L FORMATION) Date: City or Town of: To the Inspector Of Wires: By this application the undersigAcd gives notice of his or her. tention to perform the electrical work described below. Location(Street&Number) Owner or Tenant Telephone No. e Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building 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: Installation of Security system Completion of the followin table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above ❑ In- ❑ o.of Emergency Lighting rnd. grnd. 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 Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat r camp Number Tons KW No.Detection/AlertingofSelf-Contained Devices = No.of Dishwashers Space/Area Heating KW Local ❑ Municipal [I Other Connection No.of Dryers Heating Appliances Kit SecurityNo. ystemss or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. 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:) (Expiration Date) 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. I certify, under the sins andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: as LIC.NO.: l r,_1_1r Licensee: John S. Bassett Signature LIC.NO.: 1533C (If applicable, enter"exempt"in the license number line) Bus.Tel.No.• 603 594 5928 Address: Alt.Tel.No.: OWNER'S INSURANCE WAIVER: I am aware that the Li see 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� PATRICK J. DONOVAN ASSOCIATES, INC. l.lacm and Xoss .`�djastments P. O. BOX 110 WAKEFIELD, MA 01880 TEL. (781) 245-5540 — FAX (781) 245-7016 August 22, 2000 Building Commissioner City or Town Hall North Andover, MA 01845 Insured : Kristine & Kevin Lash Property Address : 15 Millpond, North Andover Insurer : Providence Mutual Ins Co Policy Number : H51690045 Type of Loss : Water Damage Date of Loss : 8/21100 Our File # : WAP31230 Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed•$1,000 or cause Mass. Gen. Laws, Chapter 143, Section 6, to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned Insured, location, policy number, date of loss and file number. On this date, I caused copies of this notice to be sent to the persons,named above at the addresses indicated above by first class mail. i Vern Laws, Adjuster VL/so SFS r m AC: ON OF INDEPENDENT INSURANCE ADJUSTERS ASOCIATKM PCEPENDEW of Massachusetts I