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HomeMy WebLinkAboutMiscellaneous - 17 FAULKNER ROAD 4/30/2018 17 FAULKNER ROAD 210/033.0-00140000.0 -- I Date . . l.Z, TOWN OF NORTH ANDOVER PERMIT FOR WIRING 0 X) This certifies that !.c ' `.'. : . J� �9'!L C d has permission to perform . . a�?�. . S _ �!��c. . . . . . . . . . . wiring in the building of . . . S. . . . . . . . . . . . . . . at . .�� .�! .u,,�E/ . . . . . . . . . . . , orth Andover, Mass. Fee . . �104—"Tic. No. .{. 9 ! . . . ..� . . . . . . . .' ELECTRICAL INSPECTOR Check# 3©O 10959 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 0 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 WINK OR TYPE ALL INFORMATION) Date: I City or Town of. NORTH ANDOVER To the inspecV of Wires: By this application the undersigned gives notice of his or)'er intention to rfo the electrical work described below. Location(Street&Number) 7 P-redkagjrl Owner or Tenant Telephone No. F 3 77 7Yf Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building I Vy ,(I Utility Authorization No. /3 YOf3 3 Existing Service�®Amps l bf-1 "olts Overhead �Undgrd❑ No.of Meters r New Service 2,6V Amps ��LAolts Overhead Undgrd ❑ No.of Meters Number of Feeders and Ampacity 0 Location and Nature of Proposed Electricalork: G ,+� ' Com letion of the follow g 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. Batte Units No.of Receptacle Outlets 6 No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiatin Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump I Number Tons KW.......... No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:- No.of Water No.o.of No.of Data Wiring:No.of Devices or Equivalent Heaters Signs Ballasts No.of Dvices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: �� � ��- � � � s Attach additional detail if desired,or as required by the 7nspector of Wires. Estimated Value of Electrical Work: 5VgO (When required by municipal policy.) Work to Start: 7elC Z 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 cove ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BO ❑ OTHER ❑ (Specify:) I certify,under tli sand pen tie of erjury,that the informationon application is true and complete. FIRM NAME: . L� LIC.NO.: Licensee: Signature LIC.No.- (If applicable,e pt" 'n the flee se Mr lin .) Bus.Tel.No.: Address: Alt.Tel.No.• *Per M.G.L c. 147,s.57 ,security work requir s epartment 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 1 ._ �J../1�t1L.�.3.i-1.L,.r1�-*-{�{r(,.�/C+.•fiiL77{{{1�7�x��"i.1.F"�a�J•j.J.d�l��®Q•{(� P .a/j'T }{� �L.1,'�1JA.LI�.IC.R'l./`.1x1 JLe�v�®��i • _ . �'�sset�-�[ �~ �'afleft•�[ ] �e-inspeetiort z'equzz'ed'($�O.QO)�( � �'ns�ectQrs'�coznznex�ts: (�nspecoxs' zgnatuxe�x�ozf�axs) .^- Pate .6+. .u-T1$L1.LLVF7.L}tli,fOIYT C-7 c �'asse�•--[ � �'aise�.:,�C� � �te�s�ectio�xe�uixe�( �0.00)-•[ � ���-/Z n iectokS'comments: L Alf* Sao,, T>Sed P (Xns iec ors',igna re nowilals) Pate ' MAR GRODM Edg'ECTXO-T: 'assetl- j ailec�--j ?fie-fnsp aeftlx8pirea($60.00)-[ 1 l:nspectors'Comments. (lnspectoxs' ignatare�noinftials) Pate ' PA.!L CAII,*`n N1'.A±ON's CAP-)► : asset.-- �`arleri--( � �e�7nspectionxequixe�($50AD)�� � ' is,�ectbX ' inure fs. . s�ectors', igu ure o itials) Pate f ss ecl�C � :�'axzer�•-( �- '�e�nsp ection xegtlired($50.00)•-[ � - �ectors' *(EaSpecioXs'SignatUxe Jao initials) Pate iUam.Alm rXo BY,YffTFD m17TMO khFT ON RITF,IF .APXA TO DEINSTEC ED 19 NOT The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 6� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legib) Name (Business/Organization/Individual). 1— Address: City/State/Zip: Phone#: �z? Are you an employer?Check the appropriate box: I.❑ I am a employer with 4. Type of project(required): ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 EJ construction I am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑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.Wlectrical repairs or additions 3.❑ I 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 repairsinsurance required.]t employees. [No workers' � CJ comp.insurance required.] 13• Other - *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. $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. Insurance Company Name: Policy#or Self-ins.Lic. #: AExpiration Date: 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 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 againstt olator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA f insura ce coverage verification. i do hereby cert' uo a the p ' s and penalties of perjury that the information provided above is true and correct. Si nature: liel�r Date: [ ?hone 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE "evised 5-26-05 Fax#617-727-7749 www.mass.gov/dia le NORTq /0- P xZia NORTH ANDOVER BUILDING DEPARTMENT Too 27 CHARLES STREET ,SSACHUStt Tel: 978-688-9545 Fax: 978-688-9542 DATE: ( ' 5-/ NAME / /(�� C h e ar ns ADDRESS `1 HAA [ C1(w eoaal- ZONING DISTRICT: TYPE OF BUSINESS: �=Uc n�" ✓1(U BUILDING LAYOUT PROVIDED: YES (NOS AVAILABLE PARKING SPACES: IU ZONING BY LAW USAGE: YES NO BUILDING INSPECTOR SIGNATURE MICHELLECRANSTON 11 F.A.ULKNEk ROAD 17 FAULKNER ROAD ...NORTH .ANDOVER, MA. 01845 NORTH ANDOVER; MA. 01845 BOOK 4882,PAGE 223 PREPARED FOR IMP 33 LOT 14 MICHELLE A. CRANSTON SEE PLAN#409 ou (f�l MAP 33 LOT.21 ' MAP 33 1,0120 43 N b 30 'W Z 5 v A 8 MAP 33 LOT 14 8,000 S.F. W z - N -P o I r-+ 00 D]Ct .I' O_ .. - , vii`lli t Li`i 2G �f� MAI' 33 1 U'I -I 1171L L l ..LL L LL_L - I i AN �Lt_ �E-XIST; 1 STORY /SINGLE FAMILY DWEL>_;/ 7 TOTAL CURVE DATA: Delta--43'38' Radius=368.0 A. Len9th=280.25' FRONTAGE=72.13' - \ 0D-11 -13 56 R=368.0 L=72.13 �A ULK , ER ROAD