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Home My WebLink AboutMiscellaneous - 165 REA STREET 4/30/2018 165 REA STREET 210/038.0-0263-0000.0 �I Date.....t .......................... J 0 Of NOR7q ej ,.t�``--,•�,�, TOWN OF NORTH ANDOVER PERMIT FOR WIRING • oma- _ ,�• a ;,SSACMUS� Thiscertifies that ...................................................................... .................... -s has permission to perform .r ..... ..— -wiring in the building of.... ` ::. .......................................................... ............................ .North Andover,Mass. Fee: .'............ Lic.No:�f ..�� :.... .......................TRic................,L....:.:.::..... ELECTRICALINSPECTUyt Check # r . 2012 Massachusetts Electrical Code Amendments CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.p.143,§3L,the J permit application form to provide notice of installao0of wilting 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:fnspector_of_Wires abandoned_and-invalidaf 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-terra 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. ule 8—Permit/Date Closed: Z % ***Note:Reapply for new permi A(K 0 Permit Extension Act—Permit/Date Closed: t�nwealth of Massachusetts Official Use Only fitment of Fire Services Permit No. /a/i F FIRE PREVENTION REGULATIONS Occupancy and Fee Checked_ [Rev. 1/07) (leave blank) /ON FOR PERMIT TO PERFORM ELECTRICAL WORK ,c to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 -. INK OR TYPE ALL WFORMATION) Date: 3 0l � �- g `O ¢ F— 3 �� :own of: NORTH ANDOVER . To the Inspector of Wires: O Q¢ o the undersigned gives notice of his or her intention to perform the electrical work described below. m V ° 'olc Number) CLU _�, TAW^, . CL CW,j .it Telephone No. � A, ,unction with a building permit? Yes EO�_ No ❑ (Check Appropriate Box) Utility Authorization No. Amps / VoltsOverhead❑ Undgrd❑ No.of Meters APs / Volts Overhead❑ Undgrd ❑ No.of Meters i h 4,Mpacity proposed Electrical Work: Completion o the ollowin table ma be waived by the Inspector of Wires. �cessed 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 Above - o.o mergency ig 11d. E] rnd. Battery Units No.of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No.of Switches LlNo.of Gas Burners No.o etection and y _ Initiating Devices 1 No.of Ranges No.of Air Cond. Toon No.of Alerting Devices No.of Waste Disposers eat aP Tlumber ons o.of a -Contained Totals: - Detection/Alertinm Devices No.of Dishwashers Space/Area Heating KW Local❑ unicip Connection Other No.of Dryers Heating Appliances KW Security Systems:* o.of ater o. ofo. No.of Devices or Equivalent Heaters KW Si s Ballasts. Data Wiring: No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications iring: No.of Devices or E uivalent AP I OTHER: ' Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: -QD,49 (When required by municipal policy.) Work to Start -3(J'QS 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 p 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 thlpains andpenalties ofperjury,that the information on this application is true and complete. FIRM N J} LIC.NO.: fly -�yI Licensee: Signature (If applicable, enter"exempt"in the license number line.) LIC.NO.: t h -(p St � Address: /]q� /per n 1�! / Bus.TeL No.: *Per M.G.L c. 147,s.5 -6 ,security work requires Department of Public Safety"S"License: AIL L cl.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:$ - 'e'er i 1 �. �'�, _ _ . . �� '�� - ��.,,�� . � �` �� -!Z L{_3a .. p P'- � . 4 i d Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. /��i 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 Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORM-4TION) Date: q -,3 0 7 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)_ I�S � � � Owner or Tenant ?'�� J Telephone NO. (63& Owner's Address I in PtA 5,4 ` Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Boz) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ 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 thYbIlowing table may be waived by the Irrs ector oWires. 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 Above ❑ In- o.o mergency ig g nd. Lrrnd. ❑ Battery Units No.of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zjnes No.of Switches No. of Gas Burners o.of Detection and r Initis ' Devices No.of Ranges No. of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers eat Pump Number Self-Contained Totals: -. "-" Tons KW No.of_"" _"" " Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Mni ucipal Connection [I Other' No.of Dryers Heating Appliances KW Security Systems:* No.of Water 0.0 No,of Devices or Equivalent Heaters ' No.of .Data Wiring: Si s Ballasts. No.of Devices or E uivalent No.Hydromassage Bathtubs No. of Motors Total Hp Telecommunications firing: OTHER: No.of Devices or E uivalent 10 Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. Work to Start: '-3(�'j�s UU,4/j .(When required by municipal policy.) Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the perfo the licensee provides proof of liability insurance includrmance of electrical work may issue unless ing"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.. d CHECK ONE: INSURANCE ❑ BOND ❑ OTHER I certify,under th ains and enalties o ❑ (Specify:) • P ofperjury,that the information on this application is true and complete FIRM N L LIC.NO.: r1h Licensee: �� Signature (If applicable, enter"exempt"in the license number line.) LIC.NO.: t'y, -/a y� Address: Bus.TeL No.:—JL;• *Per M.G.L c. 147,s.5 -6 ,security work requires Department of Public Safety"S"License: Alt L lc.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: $ L" • The Commonwealth ofMassachusetts j ! Department of Industrial Accidents Office of Investigations ��` 600 Washington Street Boston, MA 02111 { www m=s gov/dia . Workers' Compensation Insetrance Affidavit: Builders/Cont•tactors/Electricians/Plambers Aliolicant Information Please Print LeQtbly Nar 1e(Business/Organization/individual); Address: V City/state/Zip: m n)l� ��// Phone AirFeu an employer?Check the appropriate box: 1.lJ I am a employer with 4. 77. 2lemodeling f(required): ❑ I am a general contractor and I employees.(full and/or part-time).* have hired the sub-contractors construction 2.❑ I am.a.sole proprietor.or partner_ listed on the attached sheet 1 ship and have no employeesThese sub-contractors have . ❑Demolition working for me in any capacity. workers' comp.insurance. [No workers comp.insurance 5. 9• Building addition ' p ❑ We are a corporation and its . required.) officers have exercised their 10.7 Electrical repairs or additions 3.O I ain a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No-workers'comp, 0..1.52, §1(4),and we have no insurance required.]t employees. [No workers' 12 0 Roof repairs comp. insurance require&]. 13;❑.Other "Any appiicant that checks bot:#I must also fill out the section below showing their workers'compensation policy information r Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. a ;Contractors that check this box mustattaehed an additional sheer showing,the name of the sub-contactors and their workers'cam • �' p policy irfamtatron. t am an employer that.is prornding workers'compensadotn insurance for nV employees: information. Below isthe pow and job site Insurance Company Name:_' ,,,��,�,�,y SiyPi � � Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address,,—-16 S 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 Investigations of the DIA for insurance coverage verification. I do herelry ertify under the pains and penalties of perjury.that the information provided above is true and correct 1 Date: Phone#: 4 [I. Bolard d use only. Do not smite in.this area,to be completed by city or town offciaL Tow Permit/License# Authority(circle one): of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector rt Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all empIoyers 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-contmetor(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 Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' r� compensation policy,please call the Department at the number listed below. Self.-insured companies should entertheir t 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,currmt 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 futum 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 parson 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: w The Commonwealth of Massachusetts Department of Industrial Accidents Office of lnvestigations 600 Washington Street Basion, MA 02111 Tel.# 617-7274900 ext 406 or 1-8.77-MASSAFE Fax#617-727-774 Revised 5-26-QS www.mass.gov/dia