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HomeMy WebLinkAboutMiscellaneous - 1600 OSGOOD STREET 4/30/2018 (9) CIS Date...V... . ............. OF NORTF�,� TOWN OF NORTH ANDOVER * PERMIT FOR WIRING ssgCHUS� This certifies thatll...e r....... ... ...............:. ....:.. .......................................... ` J has permission to perform .. ....... . .................. wiring in the building of......... t�� . f..........l�.. `... . ....................................... at .... .. ?.. ! .......... . ...................................... orth Andover,Mass. a Fee....., ....'.....Lic.No. .t . ... ........ cl . ...... EL CTRICAL INSPECTOR, Check# 1-0 00 fit r r Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. I�]c Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (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 INNK OR TYPE ALL INFORMATION) Date: /- S-- / City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) )/0,90 D S DOC/ S Owner or Tenant S k r 0 11 0( ( LL Telephone No. d-2c£'y Owner's Address b 0 D U 6 od S . Is this permit in conjunctioCp lith a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Buildinglota A i Gy,YuzP 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: V4 , � PL�-C, pr- 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.o Emergency 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 g 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 ko No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Si ns Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: ' No.of Devices or Equivalent OTHER: n Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 6U (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 roof of same to the permit rmrt issuin office. p P g CHECK ONE: INSURA=NCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under thepains and a al ie fy, n t s o er'u ,that the information on.tl:is application is true and com ete. P P � .fP I �Y .f � PP PI FIRM NAME: . ✓ k C e, LIC.NO.•- Licensee: ��� 0(,� Signat LTC.NO.: 7 S (i► Yl/� (If applicable,enter "exempt"in the licens camber line.) +� ^^ Bus.Tel.No.• Address: ow--e ` U Alt.Tel.No.: 06 �/Q'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/Ag ent Signature Telephone No. PERMIT FEE. $ ❑ 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.GL 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 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass R1 Failed ❑' Re-Inspection Required($.)❑ Inspectors Comments: Y Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed ❑' Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ]FINAL INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Co ents: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com ry The Commonwealth ofMassachusetts - - Department o,f Industrial Accidats Office oflnvestigations 600 Washington.Street .Boston,MA 02111 -www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Cony°actors/Electri*clans/Plrimbers A�p�pueant Information Please Print Legibly Name(Busincss/Organi'zationllndividual):, Lq-r 0 L( o C (- C Address: l(a o o S Cy e S City/Stade/Zip: 1VU✓ /-A /Phone#: -V� ' _7� $Z . Are your an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑X am a general contractor and I 6. ❑New construction f employees(full and/or part time)* have hired the sub-contractors 2.❑ I am.a sola proprietor or partner- listed on the attached sheet. 7. E]Remodeling ship aud'hava no employees These sub-contractors have 8. ❑Demolition working forme in any capacity. workers'comp.insurance. 9, ❑Building addition [Nb workers'comp.insurance 5. ❑ We are a corporation and its required,] officers have exercised.their 10.[j Electrical repairs or additions 3111 am a homeowner doing all work right of exemption per MGL 11.[(Plumbing repairs or additions myself o workers' comp. c.152,§1(4),andwehaveno 12. Roofre airs y � p ❑ p insurance required.]? employees.[No workers' 13.❑Other 1GGI/ �/�1�a( I comp.insurance required.] ZI 'Any applicant that checks box must also fill out the section bel6w showingtheir workers'compensationpolicy information. t'Homeowners who submit this affidavit indicating they 2're doing all work and then hire outside contractors must submit anew affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'camp.policy information. Xamareemployerthat isprovidingworkers'compensationinsuranceformyemployees Below isthepolicyandjobsite information. Insurance Company NameAlGul;,t_Ce C u Policy#or S elf ins.Lic.#: f cl U '-4 (0 Expiration Date: '7 lob Site Address: / U Q 9�� 00 S City%State/Zip: 00q_— Attach a copy of the workers'comp ensationpolicy declaration page(showing the policy number and expiration date). Fail-are to secure coverage as requiredunder Section 25A ofMGL o.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 to violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of e IA for" ante coverage verification. I do hereby ce tr under pains and penalties ofperjury that the information provided above yis-true and correct. - Signature: Date: ! — J l� oe �_ X33 x� Y hy Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit0cense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CityMown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Coartact Person: Phone#: Information and Instruction s 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 tri the service of another under any conitract 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 emplayex,or the receiver or trustee lof an individual,partnership,association or other legal entity,employingi � ty, employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the o ccupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dlwelling house or on the grounds or building appurtenant thereto shallnot because of such employment be deemed to be an employes." 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 M the commonwealth fox 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 ofpublic 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 ziecess sub-contractor(s)any, pplysubconixactor(s)name(s),address(es)and hona -numb er(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 notrequired to carry workers'compensation insurance. if an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Y 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 andprinted 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 thatmust submit multiple permit/license applications in any given ear need oil submit mit one affidavit avit indzcating current policy information(if necessary)and under Job Site Address"the applicant should write"all locations in .(city or Cowin):'A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future Hermits or licenses. .A.new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e.a dog license orpermit 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 ciuestions, please do not hesitate to give us a call, The Department's address,telephone and fax number; ` hQ Coaugoxlwealt� o Massac vsPtts - Depart= t Offadustxial Accxdaits ( fco o�"IuveszaQus 600 Wakiagtm Street Basion,MA02111 617-7.2.7 49-00 ext 406 QT-X•-877AWI8 _ Revised 5-26-05 `ay, 617-727-7749 _ www.x>1ass,�Qv�d.:ia 1/5/2015 Division of Professional Licensure:License Search The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES .....................................................................................-................................................................................................................................................................................................. Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency More... LICENSEE Name: JOSEPH M. CASEY REFERENCES& SALEM, NH RELATED INFO NEW SEARCH Disclaimer Regarding Website License Searches Licensing Board: ELECTRICIANS Glossary of License Status Codes License Type: MASTER ELECTRICIAN TYPE CLASS: MR More... License Number: 950 Status: CURRENT Expiration Date: 7/31/2016 Issue Date: 11/22/2004 Exam Date: School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. i The page above has been generated by the Division of Professional Licensure web server on Monday,January 05,2015 at 12:18:27 PM. ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http:IAicense.reg.state.ma.us/public/pubLicenseQ.asp?board_code=EL&type class=MR&Iicense_number=000000950&color=&Ib=EL 1/1 Date..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ........... 0- , 44T 0^ A CHU This certifies that ... ....................................................................................................................... has permission to perforin ....4 e_tl_ �- L--- ......................... ...................p.................................... wiring in the building of ..........................................................2-0..V�. .......... . ................. ..... at .....................................%� ..................................................... ,4yrth Andover,Mass. Fee Lic.No. ELECTRICAL INSPECTOR Check# r -TEPNt,.JT - S-rROOIC) �JL Commonwealth of Massachusetts/ Official U Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] 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 INK OR TYPE ALL INFORMATION) Date: 12 - 19-2014 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number)4600 034oaA Gt- wner r Tenant QZ2 y PcoparT%es 73W r • Telephone No. Owner's Address 1600 05$90d St ID AC 4 Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Cy tY0.M40-c t*-( 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: 20 2Nd �I.c 4 SCu* re crp t .cjeS . Completionofthefollowingaztable ma be ivaivedby the Ins ctor of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans o.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA + No.of Luminaires Swimming Pool ove ❑ n- ❑ o.of Emergency Lighting rnd, grad. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners No,of Detection an Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump _um er _ons_ No.of Self-Contained Totals: Detection/Alerting Devices ipal No.of Dishwashers Space/Area Heating KW Local❑ Co n nnectiection [I Other Co No.of Dryers Heating Appliances KW SecuritySystems:* No.of Devices or Equivalent No.of Water KW o.o o.of Data Wiring: Heaters Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent 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:1 Z-a- 4 a 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 on this application is true and complete FIRM NAME: �. ELt�'tq'I C cr. TN C . LIC.NO.: Licensee:WA.yHt W- Spa's t Signature LIC.NO.:(6503 (If applicable ter" empt"in the license number line.) Bus.Tel.No. Address: 1 /'st.ol!J Alt.Tel.No.: *Per M.G.L c. 147,s.57-6f,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 �. Signature Telephone No. PERMIT FEE: $ v ` .. 12119/2014 09:57 9786833147 rfiur- esirui E1gTE�114,lf&d'Y1'YY) }a � CERTIFICATE OF LIABILITY INSURANCE 12 19 14 !dS CERTIFICATE Is ISSUED AS A MATTER OF IWORP4ATION ONLY AND CONFERS NO RIG UPON E F R DED BY THE POHOLOPTHS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY' AMEND, EXTEND OR.ALTER THE OVERAGE AFFORDED BY THE POLICIES Wow, D hA CE DOES O Ft NOTT H MTI A COST BELE THE ISSUING INSURER(S), AUf HOF�D EFITATIVt OR PRODUCER,AMI IRiAPORTANT: ff ttte hddsr is ► I poll>:y0e$)must W end A [SWAMa flu ec to the terms and conditions of the poky,certain policies rely require an endursan ant A ststownt o this cerlffimle does not conlar rights to The carr uts holder in lieu of such anticIrsereert PRODUCER NAS: Roberts lzi surance Agenc y P rAx 1060 Osgood Street ADoa'esS: North Andover, MA 01845 DING ae talc# (ttslsastA:MI®►rch$nts tual lnsur r Ccs IMS11R�tS:M9X'C•.rllXl�fB idZ7x• ELECT= co INC Irlquc:,. .*._.� ..� 173 E,RADY AVENUE SALE:, NE 03079 � F• Cp�RAGES CERTIFICATE NUMNER: REVISION NUMBER,, I CERTIFY IMA'f I'HE POLICE$OF INSURANCE LISTED QELQW HAVE BEEN ISSUED TO THE INSURED NAM12D ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANONG ANY REQUIREW Tf,TERM OR CWNCHTON OF ANY CONTRACT OR OT DOCUMENT'WITH RESPECT TO VAM CH THIS TE HAY BE ISSUED OR MAY PozC'AIN,THE INWRANCt APPOIOF_G SY THE POLICIES DES BED HEREIN 15 SUBJECT TO ALL THE TERMS- N5 AND CONDMom OF SUCH POLICIES.LIMITS SHOWN HAY HAVE BEEN REDUCED BY PAID tHhS poo C LY LIMT16 1POLICY NUMBER rAlr�UARMY CMP91,418419 x/13/xs 1/1 /16 LICHGCOUW&Nce $ 000 000 ,Ri4 DE RENTEDMERCIALUENERKLIA UTY r'p�n'1�IiiC9-I rizk— E 1CLARE 001! �OCCUR MDQ W(A ong pea+sn SPERSOPAL&AN INJURY S 1 0GENERALAGGRVIATE S 2 0 0.00 0GRIWATr;'.KTAPPUj6P6R PROCUCrS-CONPA7PAVG SLICY I LOG 3 AUTMOMLEUAeriz/23/is 12/2 A isa rt IN LE LAN $1��5?0� Op ANYAU'IO 8001LYINjuRY(Parr pR16o11) $ SDs O X SCHEDULED WI)RYINJURY(Pgr;9dd9M) X.HUM13AUTOS AUTOS �e<aERPY M $ a A g u B-FALLA LM X OCCUR CUP9142037 aJ13/15 Ili !16 sncw occur�rFNcs ri, 1,,000.000..-- OCINSLIAS CLAIMPMDE AGGFEGATF_, A 1 {700.000 RE ON E A MRKM160-1 MM3AMN wc"006102 1:O�GIMIU" OTw" AND IMPLOYM LIAIMUlY — ANYPRDFRI�7� IYTNFRlHxEs PM Yom'"� NIAJ E.L.MH ACC11ENr $00,000 O FIMFI Ej RIn NK) .U)ED? —j L.D15EA3E•FR tAYEE $ 500.O00 D d N �ERATRHd3�816WAL DISME-POLICYLMrT I S 500.000 r SGRiP11t7N OF OPERATIONS t LOCA IAiNS f VEIflGLES(ArredI ACORD 101,A42%MI f%Mt 1:1<SdmA#%n faM 9IX90 kfgT Oily PROPERTZES nM 1.600 OSGOOD ST LLC OUMj:g t'r"JCS P= LLC ZE STATION LLC DUNDEE REDSPR NC T.i,C HERITAGE PLACE LLC 21 Hf7GirE STREET LP ZORCM LP C/0 47Z-1 PROPERTIES 1600 OSGOOD STMT IS NAMM AS ADDITIOM INSURED AS PER THE TERMS OF THE VEITTKN CONTRACT AND AS PER THSIR n4TMMST TN Ta 1NSUREDS OPERATIONS ON A, PRn"y AND RON- CW=M7TCW BASIS, CERTIFICATE HOWER CAN TIQIN SHOULD ANY OF TILE AS DVI DESCRIBED POLICIES SE CANCELLED SIGFORE THE EXPIRATION DATE THRMOF, NOTICE WILL BE DELIVERED IN CJZZY PROPERTIES INC 1600 ACCORDANCE WITH THE POLICY PROVISIONS. OBwco ST IA40 DU=F Orrxc; PARKLLG L1t9I�TDEr STATIOTT LLC AUS REPRE9E7titt 11 A 1600 OSCOOD STREET NORTH AlMOVER MA 01945 MIC L P. ROSEVwl Ir 09 0 1988400 ACORD R rued. ACORD 25(26t WM) The ACORD name and lege are rogbftmd harks of=01110 Phone: Fax: (603) 4581.0.90 E-Mail: