HomeMy WebLinkAboutMiscellaneous - 157 WAVERLY ROAD 4/30/2018 (3)o
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This certifies that ............................................
has permission to perform.
wiring in the building of ....... .
13-7 -13-1-1
at
..... ............. North Andover, Mass..
Fei ... Lic. No.
ELi CTRICA�SPECTO/R
76
Chkk 4
11211
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Q Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. 112,
' Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank
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 INK OR TYPE ALL INFORMATION) Date: //— J - - / z --
City or Town of. NORTH ANDOVER To the Inspector of Wire
By this application the undersigned gives notice of his or her intention to perform the electrical work cribed below.
Location (Street & Number) - /-j _ 1-11,4d r.,/�
Owner or Tenant �/ �. Telephone No.
Owner's Address
Is this permit in conjunction with a buil ng permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building"� 1'7 /X1 Utility Authorization No.
- Existing Service ZGG 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 oft e followiniz table may be wdiaOy the Inspector of Wires.
i
No. of Recessed Luminaires
No. of Ceil: (Paddle) Fans
of Total
TransSusp.
Trsformers KVA
No. of Luminaire Outlets f
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- ❑
g rnd. rnd.
o. oEmergency Lighting
Battery Units
No. of Receptacle Outlets v
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Detection and
No. of Switches /7
/
No. of Gas Burners
Initiating Devices
No. of Ranges
Tot
No. of Air Cond. Tons
No. of Alerting Devices
Heat Pump
Number
Tons
KW
No. of Self -Contained
No. of Waste Dis posers
p
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ onMunne t oln El Other
No. of Dryers
Y
Heating Appliances KW
Security Systems:"
No. of Devices or E uivalent
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 Equivalent
OTHER:
Attach additional detail if desired, oras required by the Inspector qj 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 covera m 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 yn//Xination on this application is true nd complete.
FIRM NAME: ar /Z- !A LIC. NO.:
Licensee: /� a k Signature LIC. NO.:
(If applicable, ente "exempt" in the license number line.) Bus. Tel. No.:
Address: Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department ofPublic 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.
e.
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(Cisie toxs',zgnatur`,? uoxnz s) date
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sets --C aileri• C Re-Inspectzonrequired ($50.00)-C
;�ectbxs' eo7mkn.epfs:
(l�ttsp ectoxs" s�zgn�.tuz•e � Sao �nitiass? date
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The Commonwealth of Massachusetts
Department of Industrial Accidents
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:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. $
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. [ 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] i
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I 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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insuraice Company Name:
Policy # or Self -ins. Lic. #:
Job Site Address:
Expiration Date:
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 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
ldvestigations of the DIA for insurance coverage verification.
F do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
3ip-nature: I Date:
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
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 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 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:
r The Commonwealth of Massachusetts
�v
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
f
D PARTXE_'.M OF PUBLIC HEAL.::/DEPART:Ltii1 OF LABOR a IHDL'SrnS
NCTI?KATION OF DCLZADING WO?_{
All sections of this fora moat he completed in order to coWp v
t.`:e notification requizements of H.G.L. C. III 5197 �
i.. ..:.••.r..• --. ... .. _ 1 .: :. - - ... .. : T
Lead Paint Irspec_orl �4�6 Date of Inspection q -e--
Ccrt_ac_or per_orming project L:cerse Aallre/w5�30
Address of Proiect
•Bui?'ding Name (L! any) - � ... _, cc "
`St_sa* Address -/S7 ' 'fic.�.0 � --=G`o A=t. No / . .
Ci`
Deleadi^g Methcd: L?r' SC_ P::iG' G:::i(:::::
(circle aTl that apply)
PQ'r1M SAND:= CAUSTICS ?SLAG' CTS
I. '•Ot'ner'
selectsd, please
-Check one:..dwe —,ing •is:.Multi-ga y . ' si�gl_ Faatily
Mien wi'? work.:,e Hone : -a=,,
Project S_ uper7isor 'Yare_zT
Pro. er'rr Owner 7�i
eticn Date // ze 9 2 -
10,
��=�-'� '•� •weekends?... _ • .. ty_•- -- . .
M7 • Licerse T ,W06W i30
AcdzessD
CitY A�ld IjeI7 State �. Z1? OS S
Telephone %.S-07-- 6TS-
I case o¢ *^ ccmtiet what rerscm: �o !�—
n ., e_e_genc_ ,
Phone: Area -code required da689 seoo evening Ea3 ��s-39/3
00348/5 rev.11/
- In accardance with Cbaeter 773 of '-he Acts of 1987, ,x ssacbusetts General La
`- C '1'1'I_i197, 454 C:•!_4 :2ws
•r .00 and 105 CIM 460.000, notice of t.`.e date and met:;od (s) c
removal or coerira of paint, the soil or cher accessible material ccnta;n;,`
dancercus levels of lead, is tc be provided t:, ulle fol?cwi;c per;c;,s at leas`
days pricy tc t:Ie besirning o..g. f deleadi- ` --
1• Cccupants c: ., e dwell -I -g unit
2 • All otter cccupants of t•ze raside=tial
prerises, i. dry
3. Di: ectcr , C_%ilcYced Lead Visa^i•;g rra•re.^.leer: w - - _ r` -c
De^ar�`ent cf : •uhlic Eea1t.'^ 305 -
-, .`'Cilt.'1 Strae .+2:.'.1
4. Lead °e_"�vaI =rocrsr,
a --d
Dopar eat of Lab= Srdusl_ies Divi is : ' •�--, -
00 Ca-Mbridge St_aet, ?.cam 1101,
Local- card cf 7ea? "'VC --de
6. u_assaclhusetts _istor_cs_I'C.,_izsica _ - --• .
(== = re:::ses is listed cn t.`.e State Register of 174 41=ic _ lacasj .
�a L^ldersig;:ed her L-? •s�:tss�..u=dar the�
;vnzItias cf pe-,.... _a.d
as
a W:derstccd the-. C..�.:srea'_+�. e: M-assachcsetts �L�eleadi.:g egu' :licrs, 4 � �2
22.00, arid. Lead Foisoni.:g:.reventicn and C:,nt:-. a1 ?-eg'•:'.—alicns, 105 C: y60.00 and
that tye ir._oz-tet-ca c-rtai nee f l yi�ic t? '
�.Z t - lis r.�. _ ca is :.':e L.^d c:._.e_; to he 'Cest
-of his/}:er k:.c�rle-?gebelied'.
_ . .. Dat_- Signed:
_ ..
IIs ------:— _.----
:- —
e — -------
00349/6 •
d(IJ -T—SOY-)-
NORTH ANDOVER HEALTH DEPARTMENT
L p 120 Main Street
(� V l I- North Andover, MA 01845 I '�
Y L LG S L� L- c �'i C Q,
HOUS IN��F /2� ON REPORT
COMPLAINT #
COMPLAINANT (C r -,Y'\ 4::� EJ
ADDRESS OF PREMISES U -c �v
�Kw-y.ylylm-�
OWNER
OWNER'S ADDRESS /`/ /A 1 1^2
DATE OF INSPECTION:
ROOMS/VIOLATION:
i•i�
n S`f .s
2 I S
qr
4.-]
INSPECTOR
PL�'«j-p- lit CI /-),.t, ��5-� l �f�
�l Complaint _ N2 969
DATE:
LOCATION: S h., /,�i✓� -� �,y r,r, c y
DESCRIPTION :(example; strong, mild(nauseating, forced indoors,length of time)
J �z
4 1
thuJive�-��i�c
DATE:
LOCATION:
DESCRIPTION :(example; strong, mild ,nauseating, forced indoors,length of time)
DATE:
LOCATION:
DESCRIPTION :(example; strong, mild ,nauseating, forced indoors,length of time)
DATE:
LOCATION:
DESCRIPTION :(example; strong, mild ,nauseating, forced indoors,length of time)
NAME:
ADDRESS:
MAIL na (O(EILIV
BOARD OF SELECTMEN/TOWN MANAGER
TOWN HALL - FIRST FLOOR
NORTH ANDOVER, MA 01845