HomeMy WebLinkAboutMiscellaneous - 19 ROBINSON COURT 4/30/2018 19 ROBINSON COURT
210/006.0-0006-0000.0
F�
NOF. Date..................................
NORTN
Qt S��ao ��,tio
? ; Q TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
�,SSACNUSEt
This certifies that :. :..........:......... ....:.! ::. :.�.. .. ........a;': .:l.:....
..,:.. .�, .... ..
i has permission to perform ............... %^�- __, ... f .:
wrong in the building of
at."�..........I.: ...........e.l: .- ::: ��f ..... ...............................................North Andover,Mass.
Fee................�.... Lic.No:... :.., .. ..........�sv:`..............................
ELECTRICAL INSPECTOR
F F
Check # �—
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer
Permit Number:
!!
,.UsParGnsnf o`}ire Jinricad �1,�� '
Occupancy&Fee c �
BOARD OF FIRE PREVENTION REGULATIONS
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL'WORK
(ALL WORK TO BE PERFORMED WITH THE MASSACHUSETTS ELECTRICAL CODE 527 CMR 12:000))
PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date: O/�
City or Town of: Me 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)
Owner or Tenant: r*a'`L
Owner'sAddress:
Is this permit in conjunction with a Building Permit? Yes ❑ ZNo ❑ (Check Appropriate Box)
Purpose of Building: Utility Authorization#:
Existing Service: Amps I Volts Overhead ❑ Underground.0 #of Meters
New Service: Amps / Volts Overhead ❑ Underground.0 #of Meters:
Number of Feeders and Ampacity:
Location and Nature of Proposed Electrical Work
ACZA= g.4
No.of Recessed Fixtures No.of Cell.-Susp.(Paddle)Fans- No//of Transformers Total KV.
No.Of Lighting Outlets No. of Hot Tubs Generators KVA
No. of Lighting Fixtures Swimming Pool: Above ground D In Ground o #of Emergency Lighting Battery Units
No.of Receptacle Outlets No. of 011 Burners Fire Alarms #of Zones
#of Detection&Initiating Devices
No.of Switches No.of Gas Bumers #of Sounding Devices:
#of Self Contained
Detection/Sounding Devices
No.of Ranges No. of Air Conditioners TOTAL TONS:
Local o Municipal Connection o Othl
V No. of Waste Disposals Heat Pump Totals: Security Systems:
Number: TONS: KW: No.of Devices or Equivalent
No.of Dishwashers Space/Area Heating: KW Data Wiring,No.of Devices or Equivalent:
No.of Dryers Heating Appliances KW Telecommunications Wiring:No of Devices or
Equivalent:
No. of Water Heaters KW No. of Signs: #of Ballasts: OTHER;
#of Hydro Massage Tubs I No. of Motors Total HP
INSURANCE COVERAGE:Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insur
including'completed operation'coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited roof of same to the
issuing office. CHECK ONE: URANCE Z BOND o OTHER o Please specify: OeW
Estimated Value of Electra Work$ (When required by municipal policy)
Work to Start: Q Inspections to be requested in accordance with MEC Rule 10,and upon coml
rcertify,under the pains and penalties of perjury,that the Information on this application is true and complete.
Firm Name! LIC.# o�r�-F&(�
Licensee: Signal LIC.
j� (!f applicable,
/enter
/"/wrampt"in a license number line)
Address: V� �� 33 Ata 1110AI• / / /Y 0 3,P-11 Bus.Tet.# ,`o.3 All.Tel.# S19A,4tJ.
1P.2-_001 . _
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 h
waive this requirement. I am the(check one) Owner 0 OR Agent o
Signature of Ownw/Agent: Telephone# PERMIT
PHILIP A. PAGLIERANI ELECTRICAL CONTRACTOR
63 MAIN STREET BOX 633 ENERGY EFFICIENCY SPECIALIST
ATKINSON,N.H. 03811
TEL#603-3624065 FAX#603-362-5112
COMMONWEALTH OF MASSACHUSETTS
OF ELECTRICIANS
AS A REG JIOURNEYTHIS MANSELLECTRICIA
PHILIP A PAGLIERANI c
BOX 633
ATKINSON NH 03811-063
20966 E 07/31/04 38.9446
PHILIP A PAGLIERANI
'PO BOX 633
ATKINSON NH 03811
D0904-07-42 uct 04PIP42071
Iss. 03484999 CLASS OPERATOR
END.
Exp.04.07-2003 SEX M NGT.5-09 REST.
VIRGINIA W.BM ECHER
�. Date.............. .....:.....t--
r1°RTM
°f�"'° '•�"� TOWN OF NORTH ANDOVER
0 p PERMIT FOR WIRING
SSACMUS�
This certifies that / P x
has permission to perform ..........f 7rG l�'/.� .>...........tl� ..........................
wiring in the building of................. .................................
at.........1..Y..!..t�?./.�..'K.7,/:�' :exI C-T........... North Andover,Mass.
Fee.... . ...... Lic.No.141716
Check #
ELECTRICAL INSPECTOR/
419973
0040
t.ommonwea&of kwiac"M Official Use/Only
21partment 01 ire serviced Permit No.
se �>�C
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
APPLICATIONFOR 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 AL INFORMATION) Date: -1— 11-00
City or Town of: o`( '(\AQU S0( To the Inspector of Wires:
By this application the undersigned gives notice pf his or her intention to perform the electrical work described below.
Location(Street&Number) t9S0 C-
Owner or Tenant S Coy Y\ (KtC�1 ` *�Y Telephone No.Clr-I 8-(oS5-7631
Owner's Address �� m o\f
Is this permit in conjunction with a building permit? Yes ❑ No EJ (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: CA, Q (kJ Cko00 f-Q, }(.��`�t�l `��4-trrl
l
Completion of the following table may be waived b•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
AboveIn- .o Emergency Lighting
No.of Luminaires Swimming Pool rnd. El d. El Baotte 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 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 K`,1, Security Systems:*
No.of Devices or Eq uivalent
No.of Water KW No.of o.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.
Estimated Value of Electrical Work: (When required by municipal policy.)
1
Work to Start: —6 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 14 BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on th, application is true and complete.
FIRM NAME: ,C(`( Q—Q :C t G .C,. 4_ LIC.NO.: i y-I 11,
Licensee: �; Q Irk�,i(} j 0,o0o CSignature LIC.NO.: j
(Ifapplicable`en "exempt"in the license umberne.) Bus.Tel.No.: -rpt- -1015-
Address: �; 21 DC7 U \-d 0�1 C U 1 '0 Oo LJ
� � Alt.Tel.No.:
*Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. I tA 7
OWNER'S INSURANCE W ER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my sign re below,I hereby waive this requirement. I am the(check one)11owner ❑owner's agent.
Owner/Agent
Signature Telephone No.c-;)1- "�U'� ta2�ta PERMIT FEE: St72 a�
of� t ra��V`.: �s�t`��-•��✓�Y'1�
4
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...... ......
Date...
NORTH
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
,SgA US
This certifies that ...... ....... SD...........US/.. .....::�.......
.....Lam..................
has permission to perform . A4r*'.e........
wiring in the building of....... ...............................................
at....... r77 d
.................................. Orth Andover,Mass.
"71
. ..........
Fee ......... Lic.No............ . ... ... ....... ........... .....
ALEC'Ml��iN**S*P'ECMR
Check # 7t9
A Q 4 11
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Perm"No.
BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked
[Rev. 1/07] Qeave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WOR
All work to be performed in accordance with the Massachusetts Electrical Code(YEC)i 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: v
City or Town of: NORTH ANDOVER
To.the Inspector of Wires:
By this application the undersigned gives notice of his o herintention to perform the electrical work described below.
Location(Street&Number) ,j W K1 o
Owner or Tenant
Telephone No.
Owner's Address
Is this permit in conjut}ciion with a building permit? yes 5 No
\v'ic,.l� ❑ (Check Appropriate Bog)
Purpose of Building 0'>.e Utility Authorization No.
Existing Service 704) Amps ( O / of Volts Overhead Q Und rd
—T g ❑ No.of Meters
New Service 9 Amps / Volts Overhead
❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity 46
Location and Nature of Proposed Electrical Work:
u Co e
o 4 .,
Completion o the Ilowin table may be waived by the Ins ector of Wires.
a No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans No.of Total .
Transformers "7A
No.of Luminaire Outlets _ No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Ab ve - o,o mergency ig g
ern& nd. Batte Units
—. No.of Receptacle Outlets g No.of Oil Burners — FUM ARMS
No.of Zones
No.of Switches `� No.of Gas Burners o.of Detection and
Initiating Devices
No.of Ranges No.of Air Conor Tnto---�—
Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump umbeNo.of elf-Contained
Totals:
Detection/Alerting,Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal
No.of Dryers �'—'— HeatingA Connection El Other
ppliances KW Security Systems:
No.of waterNo.of No.of Devices or Equivalent
No.of
Heaters — Si s Ballasts Data Wiring:
No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
OTHER:
No.of Devices or Equivalent
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of lec 'cal Work: Q C (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVE GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the Iicensee 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:)
{j;)
I certify,under the pains andpenalties of pury, that the information on this application is true and complete.
FIRM NAME:
LIC.NO.:(7
Licensee: Signature
(If applicable, rater"exe pt"in the license ber fine.) LIC.NO.:
Address: Bus.Tel.No.:�7� 4 90�-a
*Per M.G.L c. 147,s.57-61,securi work re urres D Alt.Tel.No.:
q t 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: $
w
5
The Commonwealth of Massachusetts
k� ! Department of Industrial Accidents
is Office of Investigations
600 Washington Street
Boston MA 02111
t j www_massgov/dia .
Workers' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plambers
Applicant Information Please Print LeQibl
Name (BusinesslOrgwization/Individual): V-�
Address:
City/State/Zip: Phone #: . O CSC 7
Are you an employer?Check the appropriate box:
F7Rem
oject(required):
1.❑ I am a employer with 4, ❑ 1 am a general contractor and I
employees(full and/or part-time),* have hired the sub-contractors construction
2.[J I am.a.sole proprietor or partner- listed on,the attached sheet.x odeling
ship and have no employees These sub-contractors have olition
working for me.in any capacity, workers' comp.insurance.[No workers'comp,insurance 5. ❑ We are a corporation and its ding addition
tricalrequired.) officers have exercised theirrepairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL bing repairs or additions
' myself.[No-workers'comp, c. 1.52, §1(4),and we have no 12.❑Roof
rcpairsinsurance re uired].t employees, [Yo workers'
comp, insurance required.] 13.❑.Other
Any applicant that checks bo)#l must also fill out the section below ehow.ing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they arty doing all worst and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box mustattached an additional sheetshowing the name of the sub•conttactm and their workers'comp,p 1;cz,•i.^.am on.
t am an employer than is.provid ng workers'compensation insurance for tM employees: Below it the
informapolicy and job site
tion.
Insurance Company Name: -0 Lv
Policy#or Self-ins.Lie.#: Expiration Bate:
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 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 cert y under the pains and penalties of perjury that the in ormadon
f provided above is true and correct
Signature: Date
Phone#:
FBoard
only. Do nLone),
a,to be completed by city or town official
n: Permit/License#
hority(circHealth 2. ent 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son:
Phone#:
t:
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)acid 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 M
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 maybe 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,nottthe 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 enter their
self-insurance"license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed ie 'b . The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the 0 ce of Inv 'gations has to contact you regarding the applicant
Please be sure to fill in the permit/license number w `ah ivill ed as a reference number. In ad 'tion,an applicant
that must submit multiple permit/license applications gr______y_leaar nneee—d=Iyy-sum one affidavit indicating current
policy information(.if ess e"th applicant should write"all locations in (city or
town)."A copy of-the affidavitthat as een oarm y e city or town may be provided o
applicant as proof that a valid affi it is on file for future permits or licenses. A new affidavit must be filled out eac
year. Where a home owner or citi is obtaining a license; or permit not related to any business or commercial ven
(i.e. a dog license or permit to bum ves etre.)said person is NOT required to complete this affidavit
The Office of investigations woul ike to thank you in advance for your cooperation and should you have any questio
please do not hesitate to give us a 11.
The Department's address,telep a 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 1-8.77-MASS
Revised 5-26-05 Fax#617-727-7749
www.mass. ov