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HomeMy WebLinkAboutMiscellaneous - 1600 OSGOOD STREET 4/30/2018 (37) ka s� I BUILDING FILE I Date...,?- -cop....... t NOR71� '. o?°•tom`` "�o� TOWN OF NORTH ANDOVER PERMIT FOR WIRING �,SSACMus Thiscertifies that ............................................................ ................................ + has permission to perform ...--...: .. - .............................................. i, wiring in the building of '- l' ........................ North Andover,,. ndoverr,.M_au. s,.s.. Fees . .... Lic.No.&Jn�#........... ......... ELECRICALINCroR Check # � . 7681 Commonwealth of Massachusetts Official Use Only qNsEaMDepartment of Fire Services Permit No. VVJBOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical (MEP),527 CMR 12.00 1 W �kj'N '� (PLEASE PRINTININKORTYPEALLINFORMATION) Date: 28 C) City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his r her intention to perform the electrical work described below. f Location(Street&Number) 0 U� wer Tenant ir ZZV �Oifi1 Telephone No. , d2 Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building t< n Utility Authorization No. . Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters RV ft4#9 New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Ji1S� Number of Feeders and Ampacity !J Location and wetare of Proposed Electrical Work:o Completion of theollowin table may be waived bv the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No,of Total Transformers KVA ,,y No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency ig g nd. rnd. Bette Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection an Initiatin Devices Na.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers eat PumpNumber .Tons KW o.of Self-Contained Totals: Detection/Alertin 3,Devices No.of Dishwashers Space/Area Heatin KW Municipal g focal❑ Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of WaterNo.of No.of No.of Devices or Equivalent Heaters KW Si s Ballasts . Data Wiring: No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring. No.of Devices or Equivalent OTHER: — 7,S�d P�' t t t$' S�'�'r �N/ Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value f Electrical Work: (When required by municipal policy.) Work to Start: � (� Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE O +RAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of Habil' insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such Crage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under t erns and penalties ofperjury,that the information on this application is true and complet, (IIL FIRM NAME: GP C d. LIC.NO.: Licensee: VK �"S'01 if Signature LIC.NO.:.&603 4 (If applicabl t r" empt"in the Rcense nb r line.) Address: ,'- .e Bus.Tel.No.: `� �3 U Alt.Tel.No. oa *Per M.G.L c. 147,s.57-6f,security work require 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. $ l45-- ,1 .s- f i �i ` The Commonwealth of Massachusetts �^i f Department of Industrial Accidents Ila �, !J Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia . Workers' Compensation Insitrance Affidavit: Builders/Contractors/Electricians/Plumbers Anylicant Information Please Print Legibly Nairne(Business/Organizationlindividual):�•1 LL E L e e I t`( `, co , C . Address: 3 �Gt V e . City/State/Zip: c���}1 Q�� � Phone#:1-03- %S- �7J 2 A yIreu an employer?Check he appropriate box: Type of project(required): aro a employer with__I 4, ❑ 1 am a general contractor and I 6 employees(full and/or part-time).*. have hired the sub-contractors ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet.i ?• F-1 Remodeling ship and have no employees These su&contractors have 8. Q Demolition working for mein any capacity, workers' comp. insurance. g• ,Building addition [No workers'comp, insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs required.) officers have exercised their rep rs or additions 3.❑ I airs a homeowner doing all work right of exemption per MGL I III Plumbing repairs or additions myself,[No-workers'comp. c, 1.52, §1(4),'and we have no 12.F]Roof repairs insurance required.]t employees. [No workers' comp. insurance required.] 13•❑Other "Any applicant that checks hoe#1 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 contractors must submit a new affidavit indicating such. $Contractors that check this box mustattaehed an additional sheat showing the name of the subcontractors and their worker;'comp.policy information. I am an employer that is providing:workers'compensation insurance for ray employees: Below is the information. policy and job site Insurance Company Nam" Policy#or Self-ins. Lie.#: W C = - 8 3 Expiration Date: 3 0 //� �1 Y _o0 2 �'1 9Jo t� �,Jov Job Site Address:_N12l tn� d ✓�ity/State/Zip: HA [7/GqS� 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 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 afore:�l V f/(�, � 9 28 0 �� t- � Date• Phone#: LEBoF use only. Do not write in this area,to be completed by city or town ofciaL own: Permit/License# uthority(circle one): of Health 2. Building.Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing inspector 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-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 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,notthe 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 numberlisted 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 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. 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 Ofl"iee of Investigations 600 Washington Street Boston, MA 02111 Tel.#617-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Date...... NorrrM 6.4 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHU < This certifies that ................ .....L-L... ........ ... .... . .. .... has permission to perform ...... ....... wiring in the building of..... ................. at... ............ /......... .North Andover,Mass. FeeJ Lic.No.... ......... ...... .. .. ELECTRICAL INSPECTOR Check # '7 78`11 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. r BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Co e(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: j 16 0 7 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) 1400 OSgood St. bW l ) Owner oenan K Telephone No. Pl.�M Owner's Address I VJ 0 OS400k s1 . �0 0i`Y� 2Q 4 2 FG�n�r 1�h i a 0 q Is this permit in conjunction with a building permit? Yes LSI No ❑ (Check Appropriate Boa) 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: /06q" rz-MCA\ V a �aq ® 1tl1 te,1l (L-V1 1 Zd V, 2611 Aeki cd Completion o1rthe followin 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 El ❑ o.o mergency ig g nd. rnd. Batts Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection an InitiatingDevices No.of Ranges No.of Air Cond. Tons No. of Alerting Devices No.of Waste Disposers eat ump Number Tons KW No.of Self-Contained Totals: -.... .. .................. -- Detection/Alertincy Devices No.of Dishwashers Space/Area Heating KW Local Municipal ❑ Connection ❑ Other No.of Dryers Heating Appliances KW SecuritySystems:* No.of Water No.of Devices or Equivalent No.of o.of Heaters KW Signs Ballasts . Data Wiring: No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Ielecommunications Wiring: No.of Devices or Equivalent OTHER: , /� Attach additional detail if desired, or as required by the Inspector of PJii Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start:/d fS. 0 7 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO RAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability' urance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov ge 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: c L L C t'o'�!l t C Co Z'►.r� • LIC.NO.:16 cSO,3td I Licensee: & h W- s4i%, t'e S Signature Ltl.S LIC.NO.: Sa 3� (If applicable, enter"exempt"in thelicense tuber line. �=— Address: t. t�� (I/ Bus.Tel.No.: d` Alt.Tel.No..-kQ3-74 S-T-77-72, *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 Iiability 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:$ 1 . s A 1 The Commonwealth of Massachusem u ( Department of Industrial Accidents b Office of Investigations . 1 is 600 Washington Street Boston, MA 02111 c www.mas&govldia . Workers' Compensation Insurance Affidavit Builders/ContmetordElectricians/Plumbers Aliolicant Information Please Print Legibly Name(Business/Organiza6on/lndividual): `1 LL E L.e L IV`t C 1 }� Address: City/State/Zip: d 03C) Phone#: U 3` Z S— �I J 2 Are u an employer?Cheek Pe appropriate box: Type of Protect(required): am a employer with 4. ❑ I am a genetE contractor and i 6. ❑New constrvcti employees(full and/or part-time).* have hired the sub-contactors °n 2.❑ I am.asole proprietor-or partner listed on the attached sheet.I 7• Q Remodeling ship and have no employees Tbese sub-contractors have Demolition- working for me in any capacity. workers' comp.insurance. 9. Q Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical required.] officers have exercised their repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MOL I l.0 Plumbing repairs or additions myself.[No•workers'comp. c, 152, §t(4);and we have no 12 0 Roof repairs insurance required jt employees.[No workers' comp.insurance squired..] t1❑Other *Any applicant that checks bolt*1 must also fill out the section below showing their workers'boTfil s tion policy infbroution, t Homeowner;who submit this affidavit indicating they are doing all work end then hire outside oonMCtors must submit a new affidavit iodiaeting such tCorthaetora that check this box mustattacbed an additional ahxishowing the none ofthe sub-eounuctun;and their workers'comp.policy in&mmtion. I an an employer that is proni6MV:workers'compensation insumnee for my emloyeeLi- Below is the policy aid job site irtfornwlon. ` t-^ Insurance Company Namj '0 w Policy#or Self-ins.Lic.#: W C I ]�- �� - $3 Expiration Date. 4 3 p ©i3 -1W_-000`--o0 cfi~cr Job Site Address.&O Ossa SY, ptJi id/'j4,- 20 1-10q �rw;lvrc oCity/State/Zip:N, 4►jdd vej Attach a copy of the workers'.compensation policy declaration page(showing the policy number and expiration date} Failure to secure coverage asrequired.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 Investigations of the DIA for insurance coverage verification. . - Ido herebnc", under the pains and penalties of penury that the inforn"On provld'ed above is Ime and corned Signature: . ,,,l n A2 Date: I/Ilk 10 7- Phone#: r6. eial use only. Do not write in tkis area,to be conrleted by city or town offwial or Town: PermidLicense# i ing Authority(circle one): oard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector ther tact Person: Phone#: z d r� iy Date.......................... pORTM °�t�``°:•'"° TOWN OF NORTH ANDOVER PERMIT FOR WIRING �,sSACMUs� This certifies that ............... ..................................... ...................C.......... has permission to perform e GTL Fl S �ld cuc�lz ..... ... . .. .... ................................. . ..... .... wiring in the building of....................t S /� ......................:........................................ at......l G`......... .... } yNorth Andover Mass. Fee.S!e............ Lie.No...13'P! 19......... lr-4•C.{, ELECTRICAL INSPECTOR Check # o�� 7646 I Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/991 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with theMassachusettsElectrical Code( ),527 C R 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATI '` Date: 14 14J City or Town of: z `A���1J To the Insp ctor of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 6�4" Owner or Tenant Telephone No. Owner's Address 415;1S % Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building ®FF t L�,- 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 the following table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVI No.of Lighting Outlets No.of Hot Tubs Generators KV) No.of Lighting Fixtures Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zot 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 1.N!!!P.b.e.r Tons KW No.of Self-Contained Totals: """..""............ ''"'"'................"'.. Detection/Alertin 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 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 accor ance with MEC Rule 10, and upon completion. I cert,under th pains and penalties of perjury,that the informs n on t app cation is true and complete. FIRM NAME:ELECTRICAL DYNAMICS, INC. LIC.NO.: A13881 Licensee:GARY R.LETOURNEAU Signat71Z/ Bus. LIC.NO.:A13881 (If applicable, enter "exempt"in the license number line.) Tel.No.: Address: 72B Concord Street North Reading,MA 01864 Alt. Tel. No.: . 06—' CY—Y? 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. 0/6 This certificate is executed by Liberty Mutual Insurance Group as respects such insurance as is afforded by those companies. BM0068 Certificate of Insurance This certificate is issued as a matter of information only and confers no rights upon you the certificate holder. This certificate is not an insurance policy and does not amend,extend,or alter the coverage afforded by the policies listed below. This is to certify that(Name and address of Insured) Electrical Dynamics Inc EDI Network Systems,Inc. •� �ibe 72b Concord St utmarra North Reading,MA 01864-2607 is,at the issue date of this certificate,insured by the Company under the policy(ies)listed below. The insurance afforded by the listed policy(ies)is subject to all their terms,exclusions and conditions and is not altered by any requirement,term or condition ofany contractor other document with res ect to which this certificate maybe issued. Ex iration T e Eff./Ex .Date(s) Policy Number(s) Limits of Liability Continuous* 11/01/2006/11/01/2007 WC7-111-259257-016 Coverage afforded under WC law of Employers Liability the following states: Extended Bodily Injury By Accident X Policy Term MA,ME,NH,NY,PA $500,000 Each Accident Bodily Injury By Disease $500,000 Policy Limit Workers Compensation Bodily Injury By Disease $500,000 Each Person 11/01/2006/11/01/2007 T132-111-259257-026 General Aggregate-Other than Prod/Completed Operations General Liability $2,000,000 Products/Completed Operations Aggregate Hx Claims Made $2,000000 Occurrence Bodily Injury and Property Damage Liability Per $1,000,000 Occurrence Retro Date Personal and Advertising Injury Per Person/ v $1,000,000 Organization Other Liability 7Other Liability 11/01/2006/11/01/2007 AS5-111-259257-046 Each Accident-Single Limit-B.I.and P.D.Combined Automobile Liability $1,000,000 Each Person X Owned X Non-Owned Each Accident or Occurrence X Hired Each Accident or Occurrence 11/01/2006/11/01/2007 TH2-111-259257-036 $10,000,000 Occurrence Umbrella Excess 1 $10,000,000 Aggregate C FOR PERMIT PURPOSE ONLY O ' M M E N T S •If the certificate expiration date is continuous or extended term,you will be notified if coverage is terminated or reduced before the certificate expiration date. However,you will not be notified annually of the continuation of coverage. Special Notice-Ohio:Any person who,with intent to defraud or knowing that he/she is facilitating a fraud against an insurer,submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Important information to Florida policyholders and certificate holders:in the event you have any questions or need information about this certificate for any reason,please contact your local sales producer, whose name and telephone number appears in the lower left comer of this certificate.The appropriate local sales office mailing address may also be obtained by calling this number. Notice of cancellation: (not applicable unless a number of days is entered below). Before the stated expiration date the company will not cancel or reduce the insurance afforded under the above policies until at least 30 days notice of such cancellation has been mailed to: Office: DANVERS,MA Phone: 978-774-0300 ��� Gz.�•.a rC�. r�.lrr�.o. � Certificate Holder: MARIA ABRANTES City of Authorized Representative C/O Electrical Dynamics and EDI Network Systems Inc. 72B Concord Street North Reading, MA 01864 Date Issued: 11/01/2006 Prepared By: MA The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street V Boston, MA 02111 ,. , www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/Individual): Electrical Dynamics, Inc. & EDI Network Systems, Inc. Address: 72 B Concord Street City/State/Zip: North Reading, MA 01864 Phone#: (978) 664-1050 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 150 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. $ EJ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ME]Electrical repairs or additions 3.❑ 1 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.❑ Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#I 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 contractors must submit a new affidavit indicating such. tContractors 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. Insurance Company Name: Liberty Mutual Policy#or Self-ins. Lic.#: WC7-111-259257-016 Expiration Date: 11/01/07 Job Site Address: 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 1 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 ce unde pains and penalties of perjury that the information provided above is true and correct Si nature: Date: Phone#: V8) 4 -V50 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#: Date..... TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING CHU AIQ- 4, Thiscertifies that ............................................................................................. has permission to pe ............................................................................ wiring in the building of &;?:-/....... /400 4!371"W�) at..................................... ....... .......................... .North Andover,Mass. 3,9 Fee/25............. Lic.No.............. ............ ........... ELECTRICAL INSPECTOR Check # Ot 97 7167 Pe(-�-X'4 #- 5th \ Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit N°. 7l Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Co e(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: a 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) 1�w cr.gopa SA-- (ORMC04e) Owner or TenantIbOO N00a L�i~C PrOwIty "ctncigieMcctt- Telephone Noq"-415-45kq Owner's Address OurdCe Pr2K Atj4'6ver 4 A 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: au a tai .�� FLvart S o ii'T v\ io Podsh�,� sp�c�e (ACr0,c-S Completion of the following table may be waived by the Inspector of Wires. t No. of Recessed Luminaires No.of CeilNo.o Tota.-Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- 1:1 o.o Emergency ig mg 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.o Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons Heat Pum Number ons KW No.oSelf-Contained No.of Waste Disposers Totals ....... .I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Mun'cipa ❑ Other Connection PP KW No.of Dryers HeatingAppliances 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 TelecommunicationsWiring: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: 11 0 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 liabili insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov age is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under(lig pains and pena!t(es of perjury,that the information on this application is true and complete.�C FIRM NAME: ILL (,GM(C LIC. NO.: 656 Licensee: W b"y m Soo (S SignatureLIC. NO.: (If applicable, enter-exempt'in the license number line.) Bus.Tel. No.bQI -lbS s 1,19 Address: ( (`0.ct 2• M � o, oo Alt.Tel.No.: *Security System Contractor License required fort is work; if applicable,enter the license number here: 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. f 3 r f TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ ............................... has permission to perform ....................................................... wiring in the building of...... ....... ...................... at./. ............. ...................... ........ ,North Andover,Mass. Fee��. -)......7... LiCNo . 3.... ...... ELECTRICAL INSPECTOR Check # 7257 Commonwealth of Massachusetts Official Use OlInly Permit c�^7 rnr Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05) (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code( EC), -7 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: Ab To the Insdectof ofWires: By this application the undersigned gives nonce of hissor her intention to perform the electrical work described below. Location (Street S Number) 1600 S p S 1 w` � � Owner or Tenant �b 1110 dt,-n kv, Telephone No. Owner's Address skn f+_ Is this permit in conjunction with a building permit? Yes No ❑ (Cliecl(Appropriate Bos) 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: Id I�?� G�1✓[ Gvb tC41 �S } Completion of the following table may be waived by the Inspector of 6Vires. No. of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KNIA No. of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o EmergencyLighting No. of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones N o. of Switches No. of Gas Burners No. of Detection and r Initiating Devices No. of Ranges No. of Air Cond. Total No.of Alerting Devices Tons Heat Pump N 1mbe,- � uW r_. I'on,.. ..... ._ ............ No.of Self-Contained Na of Waste Disposers 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: c / Heaters Signs Ballasts No.of Devices or Equivalent No. Telecommunications Wiring: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 6Vires. Estimated Value of lec ical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO E 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalttes of per, ury,that the hiformation on this application is true and complete. GG FIRM NAME: � � Qt✓,A � LIC.NO.:&j1 33 Licensee: 114t� S])75," Signature LIC.NO.: (If applicable enter "esen t"in Ir a licernse member i .) Bus.Tel. No.- Address: 1i �`] 0'ti i'j,6eMl n �� Ala 44�2 Alt.Tel.N *Security System Contractor License requu-ed for this work; if applicable, enter the license number here: 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 c Signature Telephone No. PERMIT FEE: $ ��7 Generators Residential& c)each additional meter ..$10.00 TOWN OF ANDOVER Commercial: Sewer Ejection Pump: 525:00. ELECTRICAL PERMIT FEES a) including photovoltaic& Signs: $25.00 each ballast (Effective March 12 2003) generating Equip Per KVA $1.00 Smoke &Heat Detectors & 1IhT1l ivFEgS b)un-interruptible power systems, Initiating Devices: RESIDIENTIAL $2S 0;0 per KVA $1.00 Residential: $1.00 each Y3 COM1v1ERCIAL $50 QO c) batteries over 100 amp. hours, per Commercial: $60.00 up to 10 O SE CABLE ON cell $1.00 devices over 10 -$1.00 each OUTSIDE OF .BUI.LDING Heat Devices: $1.00 each Space Heaters: Air Conditioners: $40.00 each Heat Pumps: $40.00 each area heating$1.00 each Alarm Systems Security: (for fire Hydro-Massage Bathtubs/Hot Sub-Panel: $25.00 systems see smoke/heat detectors) Tubs: $20.00 each Swimming Pools: Residential: $40.00 Lighting Fixtures $1.00 each Residential: Commercial: up to 10 Devices Lighting Outlets: $1.00 each Above Ground: $25.00 $60.00 additional devices over 10- Major Appliances: (not listed) Inground: $50.00 $1.00 each $20 each Commercial Pool: $100.00 Carnival Equipment: $50.00 each Motors: (per hp or fractional part Switches: $1.00 each Ceiling Fans: $1.00 each thereof) $2.00 Temporary Service: Oil/Gas Burners: Must have Utility Authorization NUNi)er Commercial New Construction.or nResidential_$25.00 Alterations: residential $20.00 each $100.00 per 1,000 Sq. Ft. of Commercial $20.00 each Commercial $100.00 Construction Space Office Furnishings: per circuit$10 Transformers: Commercial Service Change/ (Relocatable Partitions/Cubicles) a) capacitors,Per KVA $1.00 Outlets &Fixture: $1.00 each b)ducts, conduit &conductors Repair: Nlnsi linve Utility Authorization Number Ovens Built in/Counter Top Units: (Associated Transfonn;rs)$25w $100 (first 100 amperes or fraction,one $10.00 each c)each manhole $$1010.00 meter) Panel Change/Circuit Breaker: d) each handhold$5.00 1.00 a) each additional 100 amperes Residential: $20.00 e)per KVA$ capacity or fraction. $30.00 Commercial: $25.00 6 primary feeders, $25.00 each(over b) each additional meter$25.00 Phone Jacks: See 600 volts,non-utility owned) g)vaults and equip. $25.00 each Commercial Temporary Service: data/telecommunications Washers: $15.00 each $100.00 Ranges $15.00 each it9:ust have Utility Authorization Number Receptacle Outlets: $1.00 each Waste Disposals: $5.00 each Com�;,ercial Repair and/or Recessed Fixtures: $1.00 each Water Heaters: $30.00 each Maintenance Permit: (Blanket Re-inspection Fee: $25.00 Permit)up to 2 Electricians$150.00 Repair to Service Residential: *For Multi-Family & per pair of Electricians over 2 $50.00 $20.00 Large C;DInIrIercia1 PI'ojec1. Data/Telecommunication: Residential New Construction Residential: $1.00 per port :SCC. Wiring I![ISpeCiOI',for (Dwelling): $220.00 Commercial: $30.00 up to 10 �I'ICSn�: o devices over i0=$1.00 each (with service up to 200 amps) �� ]!lust have Utility Authorization Number Paul 1�t'nnedv(1378) 623-(7.)E°6 Dishwashers & Disposals: for services over 200 amps.see below (Office Flours S ani to 1.0 ani) $5.00 Each a) for each 100 amps capacity or Dryers: $15.00 Each fraction add $20.00 *.Inspection n Emergency Lighting (Battery Units) b) each additional meter$10.00 Schedule: $ 1.00 each unit c) each additional panel/sub panel 1 ROUGH Feeders or Sub-feeders: $25.00 .I FINAL each 100 amp capacity of fractionr II3 Residential Additions/Alterations: I TRE�'�a-� (��� applicable) Residential: $5.00 each $220.00 maximum Commercial: $15.00 each Residential Service Change or ADDITIONAL Gas/Oil Burners: Underground Service: INSPECTIONS ':$25.00 Of Residential: $20.00 each $40.00'Mhave Utility Autho'ri%ation Number applicable) Commercial$20.00 eacha) one meter,up to 100 amp capacity PIC -3 $40.00 (revised 07/05) G_ b) each additional 100 amp capacity or fraction$20.00 t� R Date...... ..:..9.' . .. .. NORTH °`<<`'°:•'"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING $A US This certifies that ......; . . .Fl— . . :. ............................... has permission to perform ......6f Att'..e.... ........................... wiring in the building of.J! ZZ—z:f�...Z...a, L . ,North Andover,Mass. � .. Fee.1.7-.-5-�00 ........... Lic.No.&s-o .�............ .r1�.�r�.r., .....�. ....... . ���� ELECTRICALINSPECTOR / Check # 3d 7241 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 7 V( BOARD OF FIRE PREVENTION REGULATIONS [ Occupancy and Fee Checked Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: V11 07 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) IWO 0S 00 Owner rTenant �U4d 2 4LC ' 0 2P-4 Pr fi Hikw4 r,Mf41T Telephone No178-W1v-qy Owners Address 3 Quw PAAt•A tav t C A dt Is this permit in conjunction with a building permit? Yes 66 No ❑ (Check Appropriate Box) 5�� 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 100AMP qhsl 1?,G ill Location and Nature of Proposed Electrical Work: 201, 2,4 R. South the ACP09iS �4� �4 1441°.1 �Ni+s.t StI�ViG�' , o�iGe �►t-Ou"t Completion o the ollowin table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total r Transformers KVA t 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. Tons TotNo.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons K.W. No.o 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.o 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,or as required by the Inspector of Wires. t 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 C V GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability'nsurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov ge 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 agd penaltief of perjury,that the information on this application is true and complete. FIRM NAME: t "V0004!L TK, LIC.NO.: 14503 Licensee:W®ttdnp dye 'Sat ft.f S Signature �` LIC.NO.: It (If applicable,enter "exe pt"in to lice number lin . 9� �/► yqto�, Bus.Tel. No.: 7a Address: '7 �/4 . / Alt.Tel. No.: *Per M.G.L c. 147,s. 57"-6 1,security work regdires 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: $ ice- 2 C��. 3 �- t Z �- �'? �� f i l