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HomeMy WebLinkAboutMiscellaneous - 1550 SALEM STREET 4/30/2018 1550 SALEM STREET 210/106.B-0054-0000-0 Date..... . ..z. ...... NonrH °� •��a TOWN OF NORTH ANDOVER s PERMIT FOR WIRING 783^CHU of1�s�✓�e1 Thiscertifies that ............................ .............. ................. ............�............................ / (('�... has permission to perform .... ('..- .. ...... ...{ r......Se.rill-ce-.................. wiring in the building of........r..!z7.........��''..f..!...�a................................................. at .................................... a.l.�'d h^........�. .. >North An v r,Mass. Fee..5� ......Lic.No.?,Q-2,?,Q,:.......... .... ELECTRICALINSPECTOR Check# . 12621 l Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07j (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 MK OR TYPE ALL INFORMATION) Date: 7 vel-� City or Town of: NORTH ANDOVER To the Ins ector of fires: By this application the undersigned gives notice of his or her intention to perfo the electrical work described below. Location(Street&Number) /S,j O /��/sP�2 �1(-e Ivo- A-PL6ouer Owner or Tenant PIu SA`l Telephone No. Owner's Address IYA-AIL 1:7 Is this permit in conj!jUstion with a building permit? Yes ❑ No © (Check Appropriate Box) Y Purpose of Building 1 8P-Sl Gke,�C 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: 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- Elo.o mergency Lighting rnd. rnd. 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 I.NW 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:* e 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: 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 (1. BOND ❑ OTHER ❑ (Specify:) Y certify,under the pains and penalties ofperjury,that the information on this plication is true and complete. FIRM NAME: , Ct/yY - 4 vS'C, ,, LIC.NO.:,)09�b-14 Licensee: %[5�G c rLc Signature LIC.NO.: (If applicable,enter " xempt"in the license nu nber lin ) % Bus.Tel.No. Address: '5' �4�nid � )U,9- yQz1d � �L(JQ Alt.Tel.No. ar 7 *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 ❑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 entity shall 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 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE ECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: X--Z —/ 5--- PARTIAL ROUGH INSPECTION: Pass[N Failed Re-Inspection Required($.)❑ Inspectors Comments: • Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com ti The Commonwealth of Massachusetts _ F Department oflndustrialAccidents M _ r I Congress Street,Suite 100 Boston,MA 02114-2017 + www mass.gov/dia .q °•sM sy.y VPorkers'Compensation insurance Affidavits Buildexs/Contractors/Eiectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Le 'bl A �licant Information Gi.�n'.v1.0S yvc Name(Business/Orgabhation/Individual).' n _ Address: Phone#: g59 City/State/Zip: l(1c�_ __.•: Are you an employer?Check the appropriate box: Type of project(required): ed): em to ees fiill and/or part-time).* 7. ❑N6Vdonstructlon 1. I am a employer with P y 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. F]Remodeling any capacity.[No workers'comp.insurance required.] 9, [1 Demolition 3.E]I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11:�Electrical repairs or additions +,,r. , 12�[]:Plumbing repairs or additions proprietors with no employees: 'ed the sub- listed on the attached sheet 13°. ' Roof repairs and I have hu ❑ 5.❑T am a general contractor aA_ „ . These sub-contractors have employees and have workers'comp.insurance.t 14.C]Other 6.❑We area corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and We have iio employees.[No workers'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 tContractors that check this tioX must attached an additional sheet showing the name of the sub-contractors and state whether c r pot those,entities,have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Expiration Date: Policy#or Self-ins.Lic.#:J��' «/I v y��,� ��—e e City/State/Zip: AV0 4 0 � Job Site Address: �.J Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration.date). Failure to secure coverage as requited under MGL c.152,§25A is a criminal violation punishable by a fine up to$I,500.00 enaand/or one-year imprisonment,as well as statement maivil Py be forwarded to theffie oes in the form of a STOP 0£InvRK Oeshgations of the DIA for insurance ER and a fmc of up to 0 a day against the violator.A copy of thus stat y coverage verification. fy under ze s an ern ti of perjury fliat tlae information provided above is true and correct I do hereb : Date: Si atur Phone#: 7 k 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 Phone#• Contact Person: 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 enferprise,and including the legal representatives of a deceased employer,or the receiver'6k 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 b6 deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local Iicensing agency shall withhold the issuance or renewal of a license or permit to op6rate a business or to construct buildings in the commonwealth for any applicant-who;has not produced-acceptable evidence of compliance with the insurance coverage xequiired." Additionally,MGL chapter 152,§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 r 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 certificates)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 be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial-Accidenis. 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 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. I The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1-877-NIASSAFE Fax#617-•727-7749 Revised 02-23-15 www.mass.gov/dia