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Home My WebLink AboutMiscellaneous - 17 LINCOLN STREET 4/30/2018 17 LINCOLN STREET 210/070.0-0034-0000.0 1� I I (dNk- - - o�- S Date. ..la?. V....... r OF NORTh,� TOWN OF NORTH ANDOVER PERMIT FOR WIRING ��O•�ieo�f,4� }' ;�BgACMUs�t �, This certifies that ... 1 SYh fa f f-CC.- has permission to perform ......�/�f ... n/ ./.(... .if l ...... wiring in the building of............................e -........ ................................................... at . .......... ...............0.. ':..... .. ,North An er,Mass. Fee` . ►..' .......Lic.No. . 1.0.4... ......... ........6��... ........ ........;F `... . . LECMCAL SPECTO Chgck# I Commonwealth ®f Massachusetts Official se Only o Department ®f Fire Services Permit No. G �3 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 CR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: 2 � City or Town of: NORTH ANDOVER To the Inspector of fres: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) -,(q- Owner or Tenant �b4�-L p & Telephone No. 6/, S' 7 2- Owner's Address I IC &'-/; /C 62 r if 91- 16,, A t-0 1&/ 0 Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) ' Purpose of Building_!�71 B lm (TCR 40, a�P Utility Authorization No. Existing Service Ao Amps ?v IE>Volts Overhead No.of Meters New Service 2& -, Amps f?0 / pabVolts Overhead❑--Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans TransTotal Trsformers KVA Na:of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above In- o.o Emergency Lighting rnd. El In- El No. 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 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 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 Attach additional detail if desired,o required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,tinder the mins and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: • !¢ h'L �/ l �C LIC.NO.: /v-/o Z Licensee: S0,'i i yv�-- ako,S r , Signature LIC.NO.a o (If applicable,enter "ex mpt"in the license number ine.) Bus.Tel.No. '® •-525 Address: Q,� J �^ ® , S q Alt.Tel.No. � � S k - *Per M.G.L c. 147,s.57-61, urity work requires Department ofPublic Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that theis L ensee 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.$ 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.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 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 M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE ECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Fail e Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTIO Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comm ts: 2 Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations kvi 600 Washington Street Boston,MA. 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name(Business/Organization/Individual):_ I j yV\ I r Address: '_� �3 K `a,/ J City/State/Zip: UQ V\ QA Phone# s S a AF' I an employer?Check the appropriate box: Type of project(required): 1. m a employer with 4. ❑ I am a general contractor and I 6, EJ New construction employeesees full and/or art-time). have hired the sub-contractors 7. Remodelin 2.❑ I am a sole proprietor or partner- listed on the attached sheet. ❑ g 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 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 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' comp.insurance required.] 13.0,other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they a're 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 thepolicy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: l /) 4 J k r City/State/Zip: Attach it copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 certto under the pains and penalties ofperjury that the information provided above is true and cc/orrect. - Signature: Date: /' 7 G Phone#: 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#' F 1 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 ofhire, 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 y 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 ti employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confnmation 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 ou 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 Office of Investigations 6.00 Washington Street Boston,MA.02111 I Tel.#617-727-4900 ext 406 or-1-$77,7MASSAFB - I Revised 5-26-05 Fax#617-727-7749 www.znass,govfdia ZDate . . . . .. TOWN OFR PERMIT FOR PLOF ING a SSACows This certifies that -�-�r�- ` . ./.�,� . . . • . . . . . . . . . �� has permission to perform . .�. . -��. . �. ..,a....... .�j. . . . . . . . . . . . 4 plumbing in the buildings of . �.� t at .,�.7'.�.9�.4-- r!. . ... . . . . . ., North kn over, Mass. Fee-2.6e- . .Lic. No. .. . . . . . . . ll�� PLUMBING INSPECTOR Check p Nil 3 6993 1 ; MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING ype or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations / ' ��/G07��/ �� Permit# Amount S Owner's Name New❑ Renovation ❑ Replacement Plans Submitted ❑ 2 1 � n z i z C �-- , -- I - cn ¢ ASE .M ENT Is'r. F L 0 U R 2v D . FLOUR I 3 R D . F L 0 U R .i'rII . FLUU It i.... 5'r II . FLOG R C,T It . F L O G R I i-r 11 . FLUU It .'YT II . FLUU R (Pant or typo) Ch ck Q= Certificymte In tallim7 Co�Pany Naine ®� ��/may �� Corp. C_ Addrelss �` ❑ Parmer. Busines�, Telephone 2 ❑ FirmiCo. Name of Licensed Plumber or Gas Firter INSUR.kNCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yeses No❑ Ifyou have checked yes. please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Aaent Owner ❑ Aizent ❑ I herebv certify that all of the details and Information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions ofthe Massachusetts C Ga C e an Ch r of the General Laws. Bv: Sip-nature of Lic::nsed Plumber Or Gas Fitter Tide 04-PlumberQ�ll/� City/Town ❑ Gas Fitter ,cense Ivumoer faster APPRU`'ED(uFr(rr USEONLY) Ilf(((❑CCCJJJ Journeyman