HomeMy WebLinkAboutMiscellaneous - 18 MOLLY TOWNE ROAD 4/30/20180-1
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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 ofongoing construction activity, and may be-deemed_bythe,Inspector_of-Wires abandoned_and.invalidafhe—
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.
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❑ Rule 8—Permit/Date Closed: Note: Rea for new permiK,
❑ Permit Extension Act — Permit/Date Closed:
Date ..... f7z .... 7 .....
TOWN OF NORTH ANDOVER
4t PERMIT FOR WIRING
This certifies that ...... &—Z 77-P'.,
. ..................................................
Nas permission to perform ............ . gqq'� .......(I OG k l..............
wiring in the building of ........... 4-?�� ....... ....................................
at .... ........ —, ............... /;I�orth Andover, Mass.
Fee .... Lic. No...L.??/.-.........
Check # Lf
90) 4
Commonwealth of MassachusettsEI/
Official Use Only
Department of Fire Services No.
i411 BOARD OF FIRE PREVENTION REGULATIONS d Fee Checked
APPLICATION FOR PERMIT TO PERFORM,Ieaveblank
All work to be performed in accordance with the Massachusetts Electrical Coodd ELEC527 CMR TRICAL 00WORK
(PLEASE PRINTININK OR TYPE ALL WORAMT10N �Wj'��
City or Town of: NORTH ANDOVER ) Date: _By this application the undersi ed To .theInspector of res:
undersigned gives notice of his or her intention to pe rm the electrical work described below.
Location (Street & Number) 1��� 2�
Owner or Tenant
Owner's Address Telephone No.
----------------
Is this permit in conjunction with a building permit? Yes
Purpose of Building es` ,e Z4 42 LJ ❑ (Check Appropriate Box)
Existing Service Amps Utility Authorization No.
_ / _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 ollowin table may be waived b the Ins ector of Wires.
No. of Recessed Luminaires No. of Ceil.-Sus No. of
p. (Paddle) Fans Total
No. of Luminaire Outlets Transformers KVA
1 ; No. of Hot Tubs Generators KVA
No. of Luminaires Swimming Pool Above13In- o mergency tg g
d.— No. of Receptacle Outlets No. of Oil Burners rod. BatteryUnits
FIRE ALARMS No. of Zozres
No. of Switches No. of Gas Burners No. of Detection and
No. of Ranges Total Initia Devices
No. of Air Cond. No. of Alerting Devices
No. of Waste Disposers Heat Pump NuIts
mber Tons
No. of Self -Contained
No. of Dishwashersµ Detection/AIertin Devices
Space/Area Heating KWLocal ❑ Municipal
No. of Dryers geatin A Connection ❑ Other
g ppliances KW Security Systems:
No. of Water KW No. of of No. of Devices or Equivalent
o
Heaters Si s Data R'h'in .
Ballasts. No. of Devices or E uivaIent
No. Hydromassage Bathtubs No. of MotorsTotal HP Telecommunications Wiring:
OTHER: No. of Devices or Equivalent
.a
Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires.
Work to Start: (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
the licensee provides proof of liability «� Permit for the performance of electrical work may issue unless
h 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 ❑ OAR
I certify, under the p 'ns and enaltie o f ❑ (Specify:)
P eet 'uty, that theinfo
FIRM NAME: rma on on this application is true and complete.
a
Licensee: LIC. NO..
� TTL�'Gdl2� Signature
(If applicable, enter "exempt " in the license number line.) LIC. NO.:
Address: -�_l���i ST"n��s�i �� q Bus. Tel. No.:
*Per M.G.L c 147, s 57 61, security work requires f 3 Alt: Tel. No.:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee doles not havety ,t License:
Lic. No. 3
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owneicoverage normally
Owner/Agent owners a
Signature ❑ gent.
Telephone No. PERMITTEE: $
A
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
sista' ,' 600 Nw.shinuton Street
Boston MA 62111
wwYfJ_nms.gov%dis
Workers' Compensation Inseirance Affidavit: Builders/Contractors/Electricians/Plumbers
A licant Information
Please Print Lem I
Name (Business/o genizadon/individual):
Address:
City/State/Zip:
Are you an employer? Cheek.the appropriate box:
1. ❑ I am a employer with 4 Type of Project (required):
❑ I am a general co7+:m
oyem (full and/or part-time).* have Dred the sub -contractors 6 ❑Naw construction
2. I am a.sole proprietor or partner- listed on the attac7• ❑Remodeling
ship and have no employees These suti-contractors have
working for me .in an g ❑ Demolition
y capacity, workers' comp. insurance. g, Bwildi
[No workers' comp. insurance 5. ❑ We are a corporation and its ❑ ng addition
3. ❑required.) officers have exercised their 10.❑ Electrical reuirs or additions
I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself [No•workers' comp. a 152, § 1(4), and we have no
insurance required.] t -employees. [No workers' 12.[] Roof repairs
' comp. msusaticx required.]
ME] .Other
`�4 applicant that checks boy fi 1 must also flit out the section below showing their worker;' compensation polley information.
;Any
who submit this afiidavit indicating they are doing all work and then hire outside contractors must submtt a new affidavit indicating such.
�Coatractors that check this box mustatrached an additional sheat showing the name of the snb-
cwtmctm and their workers' comp. policy iniomtadost.
1 am an employer that is proviirwg:workers compensation assurance
informaiion. for HVemployees: Below is the Policy a>rd job site
Insurance Company Name: '
+ Policy 4 or Self -ins. Lic. #:
Expiration Date:
Job Site Address:_%7} / ��� ��,7 �Od% ,q�
City/5'tate/Lip: OJ dr•A/' /tel
Attach a copy of the workers' comtpeusa#ion Policy declaration page (showing the policy Dumber 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 paints and penalties of p ury tkat the ormation
-- - Z x ' f Provided above is true and correct
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 S. Plumbing Inspector
6.Other
Contact Person:
Phone #:
7 _
Information a nd 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, assodiation, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and includirsg 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 maiintenance, 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, VGL 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) aad 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. lfan 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, northe 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 nurnber.listed below. Self-insured companies should entertheir
sett -insurance license number on the appropriate Tine.
City or Town Officiais
Please be sure that the affidavit is compiete 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 permittlicense number which A -ill 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.
Revised 5-26-05
The Commonwealth of Massachusetts
Deparimont of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-8.77-MA.SSAFB
Fax # 617-727-7743
www.mass.gov/dia
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