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HomeMy WebLinkAboutMiscellaneous - 152 MAIN STREET 4/30/2018 © �- \ fi ��A�� � � �� G �. _� i Date...... . . ~ MORT" °� `° '•�"� TOWN OF NORTH ANDOVER PERMIT FOR WIRING COW This certifies that ............�vF.A —0.......... ....-**-********--** has permission to perform �� .....4r. ��—.. ,,........................................ wiring in the building of. .. �!-.. ....L .1. . �L i<r� ............................. at...1- Z l . ...................................................., ;`North Andover,Mass. gal Fee...L.:�s.:" ... Lic.No...1?��$ ......... . (�-.. ....�, ,�. ...`/�� . Ei411 ec rrt�c�t I►vsrecrox Check # 885 �t r { Commonwealth of Massachusetts Official Use Only V. Department of Fire Services Permit No. eT�r BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 WORK (PLEASE PRINT IN INK OR TYPE ALL NFORMATION) Date: City or Town of: NORTH ANDOVER 7/17 1 By this application the undersigned gives notice of his or her intention to perform therelectrical woctof ork described below. Location(Street&Number) Owner or Tenant �r 1 bay T- s Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes LZ No Purpose of Building EJ Appropriate Box) —� �e�+5 Utility Authorization No. Existing Service ;ZQv Amps / Volts Overhead �-y ISI 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"1� .1 )e:-• wry C7� YG2 v.� 1�2C EQy -vC(�C L� Completion of the followin table may be waived by the Inspector of Wires. No.of Recessed Luminaires K No.of Ceil.-Susp. (Paddle)Fans No.of Total . � No.of Luminaire Outlets No.of Hot Tubs Transformers KVA Generators KVA No.of Luminaires 1 Swimming Pool Above In- o.o mergency rg g arnd, grnd. Battery Units -- No.of Receptacle Outlets No.of Oil Burners FIVE Ai�ARNIS No.of Zoncs 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 Devices 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 Connection Other No.of Dryers Heating Appliances KW Security Systems:* _ No.of Water No.of Devices or E uivalent KW No. Heaters No.of of Signs Ballasts Data Wiring: No.Hydromassage Bathtubs No.of Devices or E uivalent No.of Motors Total gp Telecommunications Wiring: OTHER: No.of Devices or E uivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work:' '" � - Work to Stark (When required by municipal policy.) 09 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VE GE: 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 E?"BOND ❑ OTHER en I certify,under the pains and alties o El (Specify:) P�p ofperjury, that the information on this application is true and complete. FIRM NAME: Licensee: y,� LIC.NO.: k Signature LIC.NO.: ,53 - (If applicable, enter'exempt"in the license number line.) � Address: Bus.Tel.No ft UL-eXv.f-- *Per M.G.L c. 147,s. 57-61,security work requires D ,, „ Alt.Tel.No.: OWNER'S INSURANCE WAIVER: I am aware thatirte Licensee does not have the liability Lic.No. required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner Elnormally agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ 1 1. r The Commonwealth of Massachusetts kj ! Department of Industrial Accidents t Office of Investigations a 600 ff,ashington Street ,i Boston, MA 02111 www mass.gov/dia . Workers' Compensation Insurance Affidavit: Bailders/Contraetors/Eiectricians/Pinmbers Applicant Information Please Print LeQibl Name (Business/Orgmizafion/Individual): U,� A 1 Address:_ e City/State/Zip: �,� yPhonetx -- Are you an employer?Check-the appropriate box: 1.❑ I am a employer with 4, Type of project(required): ❑ I am a general contractor and I �mployees{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.t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for mei' any capacity, workers' comp.insurance. [No workers comp.insurance 5. 9• ❑Building addition ' p ❑ We are a corporation and its required.] Officers have exercised their 10•❑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' comp, insurance required_] 13•❑Other *Any applicant that checks boil tE l must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside conttacton: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'com .poli p c.:. n ro t I ant an employer that is providing workers'compensation ir:surawe for nV employees: information. Below is the policy and job site Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: Af.2 /l,,— e— City/State0p: 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 DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si tore: ,i Date: % Phone#: ?� Officio!use only, Do not write ui this area,to be completed by city or town official City or Town: Permit/License# Is Authority(circle one): 1. Board"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 emp ll oyers 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 I52,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contact,for the performance of public work until acceptable evidence of compliance with the insurance requirements of this capter 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),addresses)and hone numbers slop with their cenifi p ( ) sof g ) 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 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 nurrnber.listed below. Self-insured companies should enter their self insurance Iicense 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 pennit4icense applications in any given year,need only submit one affidavit indicating current policy information(.if necessary)and under"Job Site Address"the applicant shouldwrite"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 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.#617-7.27-4900 Ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-7744 www.mass.gov/dia Date. i TOWN OF NORTH ANDOVER y 3? �� �pL 0 PERMIT FOR PLUMBING r � �• r SA HUS This certifies that . .G f'. .'<! . . . `. . . . has permission to perform/. :' -•�-i:' _ � /.;•?" plumbing in the buildings of . . . . ..6 . . . . . . . . . . . . . . . . . . . . . . . . . . . at ./ ,7�. . . - '! . ... . . . . . . . . . . . . North-Andover, Mass. Fee Lic. Nor C,. ! s!s '1 Z . . . . . . . . . . . . . PLUMBININSPECTOR Check .H �� r 8144 t+ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS // M C �� n) Date 7/`b Building Location [ 5 / " �1 J Owners Name 1(jL�' [ Permit# / '/ Amount Type of Occupancy d New Renovation Replacement 1:1 Plans Submitted Yes 0 No 0 FIXTURES rZ FrA > z dw z a Fcon z x c a x w Q w E., FCL a O z A 00 ou " C M SLBBS%IF &151H1V>�TIT 1SI:IH DM M WDM 3M HA" 41N ADM SIH RDOR 61N.H DM 7M It" SIN I4IJt�t (Print or type) ' A„ ^ �,C Check one: Certificate Installing Company Name /`�``1L• Corp. Address 9 K N%bo)j Partner. 66 Business Telephone Firm/Co. Name of Licensed Plumber: G h M k& OlC tf(�2 Insurance Coverage: Indicate the type of insurancd coverage by checking the appro riate box: Liability insurance policy 11 Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance i nature Owner Agent I hereby certify that all of the de ils and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Slate PlumbCode�apter 12 of the General Laws. ALL- Y 1gna ure 01 Mcenscuum er 3 Tee of Plumbing License Title I a City/Town License Numner Master Journeyman My PPROVED(OFFICE USE ONLY The Convwnwea&k o Massach f usetts a Department of Industrial Accidents ' •. Office of Investigations ° tit!` 600 Njashington Street n$ ' Boston, MA 62111 www.mius+gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contra.ctors/Eiectricians/Plambers A• Iicant Information _ Please Print Lem Name (Business/Organiza6an/Individual): Address: City/State/Zip: Y Pi 6C y /(nq of y� Phone#: . 177 pt-1. Are you an employer?Cheek.the appropriate box: 1.❑ I am a employer with 4. Type of Prefect(required): ❑ l am a general contractor and i employees(full and/or part-time).* have hired the sub-cofactors 6. ❑New construction 2. I am.a.sole proprietor or partner- listed on the attached sheet.= 7. ❑ Remodeling ship and have no employees These soli-contractors have gff�m working forme in an t,, clition Y�paci workers' comp.insurance. 9 Building [No workers'comp.insurance 5. ❑ We are a corporation and its addition 3-13 required.) officers have exercised their 10.❑Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp, C. t52, §1(4),and we have no Insurance required.]t. tem to ees I2.❑ Roof repairs • P Y (No workers' comp. Msur-ance required.] I3.(].Other `Any eppli=m that checks bol:#l must also fill out the section blow showing their workers'compensation Hompolicy information t eowners who submit this affidavit indicating They ate doing all worts and then hire outside contractors must sttimtit a new affidavit indiotitias such ;Contractors that check this box roust attached en additional sheet showir$.the name of the sub•ca ntractors and their workers'com;.pa!iMirfomution. l am employer that is protddWrivorkers'compensation inawancefor mamPtoP eebelow is the policy and jab site . Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/Stt�t�Zip: Auah a copy of the workers' compensation policy d Failuueclaration page(showing the policy number and expiration dale Failure to secure coverage as requited 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 las civil penalties in the form of a STOP WORK ORDER and a fine In es to tions o 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 pairs and penalties of perjury that the information provided above is trr�e and rowed Si lure: �� Date: Phone#: '-Q 3a—i{3 00-44 E only. Do not write ix this area,to be completed b or town o ffxid Town: Permit/License # Issuing thority(circle one): Health 2.BuildingDepartment 3.City/Tovvn Clerk 4. Electrical Inspector 5.Flumbiog Inspector son- Phone#: Information a nd Instructions f Massachusetts General Laws chapter 152 requires all emp I oyers 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 includir•*g the legal representatives of a deceased employer,or the reaciver 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'd6 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 os-focal licensing agency shallwithhold the issuance or renewal ofa'liEense or permit to operate a business oro`coastrnct buildings in the commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insurance'coverstge required" Additionally, MGL chapter 152, §25C(7)states"Neither tlhc commonwealth nor any of its political subdivisions shall enter into any contract for the perforrrrance 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 compiem-tely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),addresses)mind phone number(s)along with their certificates)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no empioyees other than the members or partners,are not required to cant'workers' coTnpensation 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,nat'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 mamberlisted below. Self-insured mngmnim ahauld enter their i self insurtancelicense number on the'appropriateline. City or Town Officinis Please be sure that the affidavit is complete and printed legibly. The Department hes 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 indicatingcurr•ent policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of 6e;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 flog license or permit 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 # 617-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-7744 www-mass.gov/dna