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HomeMy WebLinkAboutMiscellaneous - 199 STONECLEAVE ROAD 4/30/2018 (2) 199 STONECLEAVE ROAD 210/104.B-0131-0000.0 ` j i Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. J�9 Occupancy and Fee Checked �� BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank 1 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 27 C R 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector 0f Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 2 Owner or Tenant ,,--7^-jc�f §c Telephone No. yah' Owner's Addressy,�> ' Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building L-/ 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: 2- Completion Com letion o the ollowin 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. Battery Units y, No.of Receptacle Outlets No.of Oil Burners FRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and InitiatingDevices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump I Number I 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.of No.of No.of Devices or Equivalent 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: Q© Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of E ctrl al Work: _ (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VERAGE: 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,under thepains and penalt*e o erjury, that the information on this application is true and complete. FIRM NAME: -��_ Qenv" LIC.NO.: a� Licensee: .IG"�'✓ s-z &:- Signature ,; LIC.NO.: (If applicable, ente em t"in the li numb r 1' .) Bus.Tel.No,-hs Address: tZ�40CZifZbl OOA Alt.Tel.No.-7l?/. �� ��� *Per M.G.L c. 147,s.57-61'security work requires Departinent of Public Safety"S"License: Lic.No. / f 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 SignaturTelephone No. P ERMIT FEE. Date......' ..1,7........ NOR7M °f<�``°;•�"° TOWN OF NORTH ANDOVER PERMIT FOR WIRING i �,SSACMUS� A This certifies that'... � .................................. has permission to perform wiringin the building-of................................................................................... at... r � ... ,North Andover,Mass. 1 Feed ............. Lic.No 33.. ELECTRICAL INSPE R Check # 7898 f The Commonwealth of Massachusetts ' ► Department of Industrial Accidents l Office of Investigations i1 600 Washington Street i Boston, MA 02111 fi s www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ��V;�-- C 2!!5,Z Address: �/- City/State/Zip: L� `�/ WOO,-Phone • #• �� �9' - `� Are you an employer?Check the appropriate box: Type of project(required): I.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. Q New construction employees(full and/or part-time).* have hired the sub-contractors 2.0'1 am a sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for mein any capacity, workers' comp.insurance. g, Q Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their P 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself.[No-workers'comp. c. 1.52, §1(4),and we have no 12.[] Roof repairs insurance required.]t employees. [No workers' comp. insurance required.] 13.[]Other " *Any applicant that checks box'#I must also fill out the section below showing their workers'compensation policy information. I 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 theirwork cm'comp.policy inSnnation. r l 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. Lie.#: S�J��C oz-j ±�E2 Expiration Date:�7� 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 certify under the pains enalties of perjury that the information provided above is true and correct I Signature: Date: Phone#: –.2 7 3 73 z Official use only. Do not write in this area,to be completed by city or town ofciaL City or Town: Permit/License# Issuing Authority(circle one): L6. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Other ontact Person: Phone#: IN 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, r 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-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 cant'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,nofthe Department of M- 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 Iicense number on the appropriate dine. / 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 permittlicense 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 pen-nits 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 as a call. The Department's address,telephone and fax number: 1! The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-7274900 ext 406 or 1-8.77-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.govIdle i i I I TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. - �DATE ISSUED: rn ic SIGNATURE: Building Commissioner for of Buildings Date Z SECTION 1-SITE INFORMATION 0 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 199 Sfonedeove 0 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record r marlan"P- 199 , 'tvnedeaUP t� r Name(Print) ` j Address for Service: t �= 2. Signature Telephone O 2.2 Owner of Record: Name Print Address for Service: O Z m Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Toseol G Le v cs Licensed�Cons r ,3 uction Supervisor: 0 G 6S O License Number Address G Expiration Date ` ic S ature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ 0 Tose a LC2vI s- Company -7 Company Name U M L" Registration Number r Address Expiration Date a ^� Signature,,,')-- Telephone tl, SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check all ticable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) 7Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work:l / j C- e W GU rum U cl(' N n (.� C:u i I v ryt QL cls SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAI; ISE ONLY Completed by permit a licant 1. Building (a) Building Permit Fee v� '/00 Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC pZSV 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPL OR BUILDING PERMIT I, • "�� s Owner/ thorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Signature of Owner/A 19 ent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 3Ku SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HE-IGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY , IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Location No. � Date NORTIy TOWN OF NORTH ANDOVER O:i . o :�1tiO OL � A + • Certificate of Occupancy $ Building/Frame Permit Fee $ s�CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ a Check # 16192 Building Inspector r • __ -K+w�.�.i.+:.l.Aba.,easr�;.:rr}t=a.mw+:�. ;R, �/ze�oorvnza�zurea of AamadWieM ' ` BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number-,CSd 030651 1 Birthdate:01/0711954 I1 ► , Expires 01/07/2004 Tr.no: 13385 Restrict d 00- JOSEPH G.LEMS,",' ; PO BOX 952 s,- r LAWRENCE, MA 01842 Administrator ' � ✓1ze iDomt�naorcaP,a`/s� a����/.aadac�i�cJP,�b.• i Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 103772 Expiration: 7/9/2004 ,•Type: In JOSEPH G.LEVIS Joseph Levis 65 Salem St/ Box 952 p Lawrence,MA 01842 `` " 4rlmcnictrntnr .. y .... -.1.1 UARD® Workers' Compensation and Employer's Liability Policy 1;,-4 NorGUARD Insurance Company ,• INSURANCE Policy Number LEWC4O5112 r GROUP Renewal of LEWC305O02 1 NCCI No. [25844] [1] Named Insured and Mailing Address Agency LEVIS COMPANIES INC. LANDMARK INSURANCE AGENCY Joseph Levis 198 Massachusetts Ave. 65 Salem Street North Andover, MA 01845 Lawrence, MA 01843 Agency Code: MALANDI0 Federal Employer's ID 04-3144874 Insured is Corporation Risk ID Number 000306080 [2] Policy Period From February 27, 2003 to February 27, 2004, 12:01 AM, standard time at the insured's mailing address. [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $100,000 Bodily Injury by Disease - each employee $100,000 Bodily Injury by Disease policy limit $500,000 i k C: Other States Insurance - Part Three of this policy applies to all states, except any state listed in item [3]A. and the states of North Dakota, Ohio, Washington, West Virginia, and Wyoming. D. This policy includes these endorsements and schedules: WC OOOOOOA - STANDARD POLICY WC 000001A - INFORMATION PAGE WC 000403 - EXPERIENCE RATING MODIFICATION FACTOR WC 200301 - MASSACHUSETTS LIMITS OF LIABILITY ENDT. WC 200302 - MASSACHUSETTS-ASSESSMENT CHARGE WC 200303B - MASSACHUSETTS NOTICE TO POLICYHOLDER END WC 200401 - MASS. PENDING PREMIUM CHANGE ENDORSEMENT WC 200405 - MASSACHUSETTS PREMIUM DUE DATE ENDT WC 200601 - MASSACHUSETTS CANCELATION ENDORSEMENT [4] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) r AC-ORD. CERTIFICATE OF LIABILITY INSURANCE OP IDB DATE(MNV6/0 EVIS-1 09/06/02 PRODUCER , ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION l ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Ca ano Insurance HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR One Griffin Brook Dr, S#100 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Methuen MA 01844-1865 INSURERS AFFORDING COVERAGE Phone: 978-688-4667 Fax:978-682-9037 INSURED INSURER A: TRAVELERS INS. CO. INSURER B: Levis Companies Inc INSURER C: Joe Levis 65 Salem St Box 952 INSURER D: Lawrence MA 01842 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LSRITR TYPE OF INSURANCE POLICY NUMBER DATE MWDDIYY-PaICY EFFECTIVE DATE MLICY M/DD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $1000000 A X COMMERCIAL GENERAL LIABILITY I680930D7438 06/23/02 06/23/03 FIRE DAMAGE(Any one fire) $300000 CLAIMS MADE �OCCUR MED EXP(Any one person) $ 5000 X PERSONAL&ADV INJURY $1000000 GENERAL AGGREGATE $2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2 0 0 0 0 0 0 POLICY PRO LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ EA HANY AUTO OTHER THAN ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY EACH OCCURRENCE $ OCCUR FICLAIMS MADE AGGREGATE $ $ $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AND TORY LIMITS ER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ E.L.DISEASE-EA EMPLOYEE $ E.L.DISEASE-POLICY LIMIT $ OTHER A Installation I68093OD7438TCT00 06/23/02 06/23/03 PROPERTY 31029 Builders Risk DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS carpentry - 210-212 Park Street, Lawrence, Ma CERTIFICATE HOLDER N ADDITIONAL INSURED;INSURER LETTER:_ CANCELLATION BREAD0 2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL -1D_DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL aui; IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR A n REPRESENTATIVES. AUTHORIZED REPR ATIVE Smallsiness ©ACORD CORPORATION 1988 ACORD 25S(7197) North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A.. The debris will be disposed of in: �-�l cr �► �c.c C,v u S� S q�P y,.1 � l� (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through.the Office of the Building Inspector NVn � �y E Town ® ► r� Andover No. ya _ �` o �o�H� c * dover, Mass.,WIC 3 ADRATED S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT BUILDING INSPECTOR �`�� ~� ��� d ................................................................................................................................................. Foundation has permission to erect...V W4.1... �,�, N t C�! ►V t. Rough .............. buildings on ... .........q..... ................... to be occupied as..$ 00 �r • W t N go i*0l�O r► f Chimney ..................! .. ............. . ../............ ..................................... ►.... ........................................ provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Cods and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. '� PAS r AA J%ft 4 ob 104113 ! ' PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCT19N ST TS ELECTRICAL INSPECTOR C Rough ......... ...... ......................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place-on the Premises — Do Not Remove Fnah No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SID Smoke Det. . • 'a��dGnuSerrsL407r_c7upancy Official Use Only Department of Fire Services o. ,�a� �� BOARD OF FIRE PREVENTION REGULATIONS and Fee Checked _ (leave blank APPLICATION FOR PERMIT TO PE All work to be performed m accordance with the Massach RFORMElectrical�ELECTRICAL WORK (PLEASE PRINT WINK OR TYPE ALL INFO NEC),s27 CMR 12.00 R�4T1019. Date: City or Town of: NORTH ANDOVER By this application the undersigned gives notice of his or her To the Inspector of Wires:. Location(Street&Number) intention to perform the electrical.work described below. N�' . �� `C Owner or Tenant �R��c Owner's Address Telephone No. Is this permit in conjunction with a building perrain, Purpose of Building Q Yes �• Na ❑ (Check Appropriate Boa) Utility Authorization No. Eaistine Service-� Amps J�Volts Overhead ❑ Ung No.of Meters Lew Service Amps / _Volts . Number of Feeders and Ampacity Overhead❑ Undgrd ❑ Na.of Meters Location and Nature of Proposed Electrical Work: 1 Co letion o the followin table may be waived by the Inspector of Wires No . Na,of Recessed Luminaires .of Cert-BessP, (Paddle)Fane No.of Total No.of Luminaire Outlets No. of Hot Tubs Transformers KVA No. of Luminaires Generators KVA Swimming Pool .Above � in- a. ❑ o,o mergency Q � No.of Receptacle Outlets d' Batte Units A �No. of Oil Bna-nets . No. of Switches FIRE ALARMS No. of Gas Burners a. of erection and No.of Ranges No. of Air Con d• oral InitiatingDevices ' No.of Waste Disposerseat Tons No. of Alerting Devices To s.'--umber Tons o. of elf-Contained No. of DishwashersDetection/A1 " Q Devices Space/Area gear KW Local[] Municipal No.of DryersConnec ion Other Heating Appliances KW Security systems.* Na.of Water a of Na of Devices or E uivaent lHeaters ' Si B Na.gallasts Da N Wiring; ydromassage Bathtubs o.of Devices or E aivaient No. of Motors Total HP Telecommunications iring: OTHER No.of Devices or E uivalenf Estimated Value of Electrical Work: Cd 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 Iicensm provides proof of liability insurance opermit for the performance of electrical work may issue unless undersigned certifies that such cov a is in force,and including completed operation"coverage or its substantial equivalent The has exhibited proof of same to the CHECK ONE: INSURANCE n BOND ❑ OT R Pmt issuing office.. I certsfy,under the pains and penalties.o er u ❑ (Specify-) .fP ! ry,that the irtforneadon on this app[u:ai!ion is true and complete, FIRM NAME: 01 '0 .-- l'v,R/�C Licensee: Aj4qX-,jf r `;;6LIC.NO.: Stature (If applicable, enter exempt^to the license number line.) LIC.NOuwx�krr Address: Bus.Tel.No.:*Per M.G.L c. 147,s.s7-61,security work requires D Alt TeL No.: OWNER'S INSURANCE W ePar�o of Public Safety"S"License: Lic.No. RIVER: I am aware that the Licensee does not have the liability'required by law. By my signature below,I hereby waive this re t1 Vance.coverage normally Owner/Agent quiremeat I am the(check one) owner ❑owner's agent signature Telephone No. PEIthI1T FE e"— E. .S' 2 - S . V i I ^�S NC-�D �v•ot/`� �w. 1 I � I r i Date...............'! . '.: ...... NORT" TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACHUS ` v This certifies that .....G;......:�-r--Ute.... ......74...................................... has permission to perform . ............................................. wiring in the building,of... _ '.....O -................................................. at... ._ �- ? <`, �-� �� ?�.. . `.,North Andover,Mass. Fee's................... Lic.No /�,�..............(�.✓. ... .. . 1 ELECTRICAL INSPE Check # Q `I 07 Comm ftweajtk of Mazachftseft" Depactrnertt ofindustrial Accident 1 ;HI4 Office of�iiv ;afiorrc tie r 600 Fdrhine. on,street Boston , MA 02111 • Workers' Cote enation In" WWW�sgay/dr'a A Iicant Ifflrmation urance A,f6tiavif: Builders/Contractorsmectriciafts/PI®bers Name,(Byainasst Please Print Legibly Orgaaizatiati/lndividuat): � y a� r j � Address: : r .Phone Are you as employer?Check the appropr.=te•bo= I.❑ I°am a employer with 4, �] I am a genual contractor and I T)pe.of project(.. . � �m *: 2.[3employ=(fiill and/or part-time).*. have hired the sub-corrtsactars 6 []Now construction ..l am.aso}e proprietor:or Partner- Iisted ship and have no employees These ,:the��tit t 7' ❑Retaodeiatg sub-Contractors working for mem have �y caP�ity.. work Com insurarl�, g' Q Demolition— [No workers'comp,insuran, 5. P 9. Bw7di ❑ �Ve are a corporation and it .. ng addition required] affic=have exercised their I O.E]Electrical 3.� lama homeowner doing all work n '"P additions myseIf».ENO.wor sirs,COM °f ex=Phon Per MGL I I.(]Piumc P Ij2, §14 'and we have no reP or additions Insurance nqulred.]t .employees,[No workam! 12.[]Roof repairs `�+nYapptic�ntthat Comp. imurancerequired_): 13.{].Othor checks this U I mu8 also fill out the section below showing their ovorlcerti'ooiapeneatioti Policy t Homeowoets who sabmir this of $Caatraeton that cheek this box oohed as glbsy am doing an w_*and thmi hhe outaWe p u7'mfomuihon. eddifonW she-rsl � must submits new R' g the sant Of the ofndevit iod' . ��sg such. air.or.eimpsui-cntnctlts e�:�rir� + infarmafion. ei t is;orPvidng:warkers'caarperlsatio�irrsuranee or �s -"'� policy inommlion. �' 1oJ'eet Below$. PDAL andh see Insurance Company Name: Policy#orSelf Iins.Lia#: . Expiration Date: • Sob Site Address: ci pq 46 Attach a copy of the.workers' com Ctty/g� �: pensation policy decf$r&tioo pa,_e(showing the policy number and Paiipre to .secure coverage as required under Section 25A of expiraEioa ds4e}. . f fine up to$1,500,00 and/or one- ear. MGL c. 152 can lead to the imposition of crsniinal Of up to$250.00 a Y imprisonment,a ni,as well 8s civil penalties in the form of a Petrd}ties of a �3'agairls'tthe violator. Be advised that a c STOP WORK ORDER and a fine Investigations of the DIA for' coverage erificati ° of this statement may be forwarded to the Vic:of msln soca cov v on I do hereby certify under the pu aUdP=ffL6z o Pe7ury thm'the informafiM proms�,e is true and correct Si / Date: Phone#: ` ::. OfftciQl use only. Do not wrrte iri.tfr�s area,to.be eompiexed.h Yor town 1' ofj cia1 City or Town: Issuing Aiiftio ` e Pernik/License# My Circle one): I.oohed otHeslth E Other 2.Buildin Department 3.City/Town Clerk d.Electrical Inspector 5 Piambing I nspeet`.or Contact Person: Phone#r K' 106rmatian and Instructions Massachusetts General Laws chapter 152 requires all emp loyers to provide workers' compensation for their cmployees. 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 ormore ofthefrnegoing engaged in a joint entmin ise,and includivig the legal representatives of a deceased employer,or 8 e receiver ortruster•of an individual;partnership,association or.other legal entity,employing pioyem'Howcverthe owner.of a dwelling house having not more than three apartem ments and who resides therein,or the occupant of the dwelling house of another who employs,persons to do maint==ce,construction orrzpair wcirk on such dwellinghouse or on the grounds or building appurtenant thereto shall not because of such employmerit be deemed to be an employer," MGL chapter 152,925C(6)also states that"every state or- local ficensing agency shall withhold the issuance or renewal of a license or permit to operate a business or .to construct buildings is the commonwealth for any appficaat who has not produced acceptable evidence.of aompiiance with the insurance bovomge required." Additionally,MOL chapter 152,§25C(7)states"Neither the commonwealth-nor any of its-political subdivisions shall enter imo any cantnict for the perftmrance of public worse until-acceptable evidence of compliance with the insumm requirements of this chapter have been presented to the contracting authority," Appiiceats . . Please fill out the workers'compensation aSidavit completely,by checking the boxes that apply to your situation and, if necessary► supply sUb-contractar(s)name(s),address(es)azrd phone number(s)along with.tie cerrificate(s)'of insurance L im. itrd Liability Companies-(LLC)or Limited Liability Pm-merships(LLP)with no employees otfier m the members m partners,are not mluireed to cagy workers'cQrnpensafim insurance. If an LLC.or LLP does have employees,a policy is required Be advised#hat this affidavit may be submitted to the Department of industrial Acciderm for confirmation of insurance coverage. Also'be sure to sign.and date the affidavit The affidavit Should be returned to the city or fawn that the application for the permit or license is being mq.uested, not`ha Department of industrial Accidents. Should you have any questions regaar-ding the law or if you.are required to obtain a workers', compensation policy,:picase•call the Depiatnent st tyre n unber.listed below. Self-insured companies should entutheir self iFrccaance".iicanse mtm=w the approprit to line. City or Town Officials Pieria be sure that the affidavit is complete and pritrted 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. Pleas be sure to fill.in the permit/license number which v►-M be used as a r inference number.. In addition,an applicant that.must submit multiple.pamit/license applications in any given year,need only submit one-affidavit indicating,mmrnt policy'informsfion(if necessary)and under"Job Site Address"the applicant should writ."all locations in (city or town)."A copy of`he affidavit that has been officially stamped or marked by tae city or town may be.provided to the applicant as proof that a valid-affidavit is on file for futwm perm or licenses. A new affidavit must be filled out each year.When a home owner or citizen is obtaining a license or permit not related to any business or commercial.verdure (i.e. a.dog license of permit tx)bum leaves etc.)said porsors,is NOT required tA:,complete this.affidavit 1. The Office,of Investigaations would tike to:thank you in advance for your cooperation and should you have any questions, °\ Pie=do not.hesitate to give us a call., The De:limm out's address,telephone and fax number. . The Commonwealth of Massachusetts Dcpartraient of Industrial Accidents Office of-Tuvesfiesfaons 600 Washington Sheet Boston, IIIA 02111 TeL#617-7274900 ext 406 or 1-977-AUSAFE Revised 5-26-US Fax#617-727-7749 u wsnass.govidia.