HomeMy WebLinkAboutMiscellaneous - 20 EMPIRE DRIVE 4/30/2018 (2) l
f
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,§K.
Permits shall-be limited as to the time ofongoing construction activity,and may be.deemed_by-the lnspector_of_Wires abandoned-and_invalidzf 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
puipose 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.
�ule 8—Permit/Date Closed: �"� -.l *k*Note:Reapply for new permit
❑Permit Extension Act—Permit/Date Closed:
1 0 1t, 4 Date......
/...:..1.�`.�. .1..
AOR7h
:•1"° TOWN OF NORTH ANDOVER
j PERMIT FOR WIRING
,SSACMUSEt
This certifies that ..........1.
. �.........
67
r
has permission to perform ...............GG U ......... ....... ..................
wiring in the building of....... ....d. O/ ................................
cl ��
at................L".�.........f.�.�..................Pe......... .. .. North Andover-Mass.
I
Fee..s'5......... Lic.No....70 ',. ......
f ELEcrRICAL INSPETOR /
Check # 7 /J
I
i
l,ommoawealth olMaaackwmtb Official Use Only
2epad..t of3
ire Serviced Permit No. L1P) 2 /
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (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 IN INK OR TYPE ALL INFORMATION) Date:
City or Town of. A,\d1Zj t_r To the Inspect4 of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) a y L rY.p � r R_ To y- i
Owner or Tenant 3S h V,0. S Q a\p Telephone No. CI78 _)Y8 -7.570
Owner's Address S oyyel R�
Is this permit in conjunction with a building permit? Yes ❑ No ® (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: Install residential security system
Completion ofthefollowing table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
4 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
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. Tota Tons g o.o
No. Alerting Devices
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 Kms, Security Systems:*
No.of Devices or Equivalent
Y No.of Water No.of No.of
Heaters K�'�' Data Wiring:
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: !g LJRC1 (When required by municipal policy.)
Work to Start: I I 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:)
1 certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: Nightwatch Protection, Inc. LIC.NO.: 7 0 2 4 C
Licensee: Paul DelSignor Signature P Al
. IC.NO.: 7024C
(If applicable,enter "exempt"in the license number line.) Bus.Tel.No.• 888-722-9282
Address: 22 Briarwood Drive, Westford, MA 01886 Alt.Tel.No.:
*Per M.G.L. c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. SSCO 0 0 0 0 9 6 9
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 PERMIT FEE: $
Signature Telephone No.
MORTM� t i
M
'y'fin.✓N'Q
CERTIFICATE OF USE & OCCUPANCY
TOWN 07 NORTH ANDOVER
Building Permit Number 699-2011 Date: July 19, 2011
i
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 24 Empire Drive Lot 3 North Andover MA
01845, 40B
Orchard Village, LLC
MAY BE OCCUPIED AS single-family_IN ACCORDANCE WITH THE PROVISIONS OF
THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS
MAY APPLY.
Certificate Issued to: Orchard Village,LLC
44 Great Pond Road Drive
Boxford,MA 01921
Building Inspector
Fee: 100.00 previously paid
Receipt: 24070
ORTH
TONM of And
h a�
LAK dower, Mass., J
COCMICMEWICK
AoRATEO p'? 5
`S V BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
` , f BUILDING INSPECTOR
THIS CERTIFIES THAT......... .1� /'d �/ - .l.
..�...................................... ...... ....................................................................................... Foundation �2 /
�( �.n-�...1....,..�....... ..
has permission to erect........................................ buildings on .............c�.. .......'�!h. � IJ��-
to be occupied as..... .1 .. ... .�-...... ..... . ......!..�.—.�.,.... 1..... . ....................................................................
Chimney
provided that the person acc'bpting this permit shall Fn every respect conform to the terms of the application on file in
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of al -;7-1,1��11
Buildings in the Town of North Andover. --PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations*Voids this Permit.
Final3?60 PERMT EXPIRES IN b MONTHS
d U _
ELECTRICAL INSPECTOR
UNLESS CONSTRU N STARTS Roug �i,; ��/
... .... ....... ...... ................................................................................... Service
BUILDING INSPECTOR
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not RemoveFi 1 a L�. 7/c��if
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No. -P �/��
-REVERSE SIDE Smoke Det.
s�
I&ORTIi
04.
to+,rsgyp`
F- o
LAM
a
rao
APPLICATION FOR CERTIFICATE OF OCCUPANCYIINSPECTION
Building Permit#
ADDRESS/LOCATION OF PROPERTY L U-e
Map /070 Parcel 1u0411?i Lot Number
SUBDIVISION
DATE REQUESTED FILED/READY FOR INSPECTION 7
CLOSING DATE ON PROPERTY: 7 /
FIVE(51 DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED
ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE-
INSPECTION FEE OF TWENTY DOLLARS$20.00)WILL BE CHARGED IF THE STRUCTURE
DOES NOT MEET ALL APPLICABLE CODES.
Ixa =L MG%J I��._- A lV..1_ C�I�iN l I LL AC 1-4-C-
G11 44 �7�7
Address a S
SIGNED .SS�,W.0(
BO-TING
CONSERVATION t-74)1
PLANNING*
DPW.-.WATER METER
SEWER/WATER CONNECTION
NOTE
DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO
SUBMITTAL.OF THE OCCUPANCY/hYSPECTION REQUEST
DPW ) ^�
Signature
•
File: Application for OC form revised Jan 2007
Date. .0
8960
yjI
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
♦ � a
,SSACMUS� /
This certifies thatz'---,Xd!
has permission to perform . . . . . . Am-4--5.C. . . . . . . . .
plumbing in the buildings of
at . . . . . . ... m— 2. . . . .F-1. . . .. North Andover,, ass.
FeeAo?.. .Lic. No../0.34.6 . . . . .
' PLUMBING NSPECTO
Check ." ,Y ��
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town:WMI� NA&A-A-r MA. Date: 'Cl-U Permit#
Building Location: t---V tk3 # ZY Gy,, �O vers Name: O&C,%A/W 4AI-L LJ( C .
Type of Occupancy: Commercial❑ Educational❑ Industrial ❑ Institutional❑ Residential C9''
New:[ Alteration: ❑ Renovation:❑ Replacement: ❑ Plans Submitted: Yes❑ No❑
FIXTURES
DEDICATED
Z SYSTEMS
W
z
Il-
z 0 N
z to �, D
LAJe Z Y
v� h = � vi p O
AL `^ tn Z H Y ¢ v� Q W t7 Uj Z L"
AL a z in
a 3 m W a �% Y v, a X a LLA a
Q: (7 ' Q W O Q Z 0: W O W _z W J z U a i< x J W a
G Vf W oc OC Ot! O 3
W F OC O h J K N W
XZ
CL z �n F t-
O Q p a H
oc Q Q aN O 0 Q >Q p = a a a v Q ¢ oac a
a m m o o LL x x a F 3 3 3 o
SUB BSMT.
BASEMENT i
1'FLOOR ( ( I
2ND FLOOR ( 3 1 Z
3"D FLOOR
FLOOR
FLOOR
6T"FLOOR
7'FLOOR
FLOOR
Check One Only Certificate#
Installing Company Name: pLl MI!il FX- eL AC-AT14
[/Corporation �rcl(o
Address: P•o, WX 1701 City/Town: PVC-P if-ELL State: P1-4,
Business Tel: CIS$- 3'21I- 1710 Fax: q 78"Sal-14130l ❑Pian/Company
Name of Licensed Plumber: STEPAG4 C. (;iCiLSiJgK�
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes R No❑
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Q� 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By Type of License:
Title Signature of icensed Plumber
Plumber
City/Town [Master
APPROVED(OFFICE USE ONLY
piourneyman License Number: I03y`8
i
I
FINAL INSPECTION i BELOW FOR OFFICE USE ONLY PROGREK INSPECTION(S)
i
FEE: $ ! PERMIT#
i
APPLICATION FOR PERMIT TO DO PLUMBING
I
i
! NAME&TYPE OF BUILDING
I
I
I
LOCATION OF BUILDIN
SKETCH
i
I
i
PLUMBER
I
I
i
I
LICENSE NUMBER:
I
i
PERMIT GRANTED E1 -DATE
i
I
PLUMBING INSPECTIOR
i
i
•
/ 66, Date.. I , /t'.•.. ....
r
NORTH
t 3=pya�.ao ,e,hOL
TOWN OF NORTH ANDOVER
O � 9
t - PERMIT FOR GAS INSTALLATION
. y
�,SSACMUSE�t
This certifies that . . .(.� .f f'1�� C. . . : . . . . . . . .
has permission for gas installation hoz/.S.-
in the buildings of . . .
at ,, .( 4 . . .� �t.t!eP . . . . . . . . . . . .. North Andover, Mass.
Fed",/ 0.•u-'I.. Lic. No.,/( . . . . . ../ .
GAS INSPECTOR
Check#
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town: NAJJ 7� V"S-y( J t.- MA. Date: 5^ • - \ Permit#
Building Location: �`0'� 3 c�-� Ew4 D)&f _Owners Name: OYtt✓WP.17� 1A \ 1,C,<-
Type of Occupancy: Commercial ❑ Educational❑ Industrial ❑ Institutional ❑ Residential[�
New: C9' Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑
FIXTURES
I
U) vi
w X U) vi 1
Z HU =
Q
w � U) O
D
• y U m = 1-- U) O w W-
z
Z w a) 0D O
F-- Q � H �
QLLJ
IL W O
Ix > w U Z w w O a W m O a = LL
W W H 0
W z O J H H O Z J O W
> U W H W W
O W >- W W lr W W m W O zz O U) F- > z ~ _ -
U 0 0 u_ a O 2 = J O a a W > > > S O
SUB BSMT.
BASEMENT 1
1 FLOOR
2w FLOOR
3 FLOOR
4 FLOOR
5 FLOOR
WH FLOOR
7 FLOOR
$ FLOOR
Check One Only Certificate#
Installing Company Name: GALII,5KY PLt1AQtIJ. d i{CIQITwG
12f Corporation 3016
Address: P.O. WX 1701 City/Town: NA►QRKZLL State: i1'1.A
F1 Partnership
Business Tel: q7g-3?y- 17y 3 Fax: C171- 5,21-411i
❑Firm/Company
Name of Licensed Plumber/Gas Fitter: ATE P N CO3 C. GALZ 051<4
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes r(No❑
If you have checked Yes please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy I?,- 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
By checking this box ;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Type of License: (?
By [t t 'mber C
Tale ❑Gas Fitter Signature of L ensed PlumberlGas Fitter
[ZMaster
City/Town )]Journeyman License Number: j0. q%
APPROVED OFFICE USE ONLY ❑LP Installer
1�.--�- FINAL INSPECTION
BELOW FOR OFFICE USE ONLY
PROGRESS INSPECTION(S)
FEE: $ PERMIT#
APPLICATION FOR PERMIT TO DO GAS FITTING
NAME&TYP L OF B IIJ pjNQ
LOCATION OF BIjIL12INC,
SKETCH
PLUMBER GAS IZEEIL LE rNSTA r i c
LICENSE NUMBER:
PERMIT GRANTED 'DATE;
GAS FITTING INSPECTIOR
r"
10-1 08 Date...,/
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
CHU
This certifies that ........................... .... .....................
has permission to perform ....... ....... ..........................
wiring in the building of...... .......
.................................................
at k,77,3........z-0 ........ ef�/rg North Ando er,Mass.*
Fee.y ...... Lic. . ..... . ... ...... .. .......
E
Check #
Commonwealth of massachuseftsFu
Official Use Only
Department of,dire Services ///a,BOARD OF FIRE PREVENTION REGULATIONS nd Pee Checked
® ®g p �pleave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WOR.
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINTMINK ORTYPEALL WFO TION Date:
City or Town of: If Z s 6J
To the Inspector of Wires:By this application the undersi ed gives no ' e of his or her intention to perform the electrical work described below.
Location(Street&Number)
Owner or Tenant
l fJl 12Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes
Purpose of Building • /-- No ❑ BLDG PERMIT#
�7 � wt tility Authorization No.-&a.7. 9 �, 6
Existing Service A ps _/ _ olts Over ad
❑ Undgrd❑ No.of Meters
New--.Service 2 6-cl Amps 20 /� 4 Volts Overhead
Number of Feeders and Ampacity ❑ UndgrdNo.of Meters
Location and Nature of Proposed Electrical Work: -
Com 1PH—ofthe following table may be waived by the Ins ector of wires.
No.of Recessed Luminaires No.of Ceil:Sus No.of
p (Paddle)Fans Transformers Total.
No.of Luminaire Outlets No.of Hot Tubs KVA
No.of Luminaires
Generators KVA
Swimming Pool Above In- o•o mergency ig Ing
No.
rnd. rnd. Batte 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
No. of RangesInitiatin Devices
No.of Air Cont,. Total
Tons No.of Alerting Devices
No. of Waste Disposers Heat Pump Number Tons KW No.ofSelf-Contained
Totals: .........._..... ..........
Detection/Alertin Devices
No. of Dishwashers Space/Area Heating KW Local❑ Municipal
No. of Dryers Connection El Other
rS' Heating Appliances KW Security Systems:*
No. of Water No.of No.of Devices or E uivalent
Signs Bal
Heaters ' BData Wiring:
Ballasts No.of Devices or E uivalent
No.Hydromassage Bathtubs No.of MotorsTotal HP Telecommunations Wiring:
' ic
OTB,R. No.of Devices or E uivalent
Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of wires.
Work to Start: f Ls (When required by municipal policy.)
Inspections to be requested in accordance with ME
INSURANCE COVERAGE: Unless waived by the owner,no permit for C Rule 10,and upon completion.the performance of electrical work may issue unless Covera s
the licensee provides proof of liability insurance including ,completed operatione
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing officeuivalent. The
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER
Icertry, under thepains andpenalties o er�'ac that,the information on this application is irate and complete
,IRIi�I NAli1E. f/P` 1 rJ', .�
9 / Lv/
Licensee: �r� � /,-' LIC•NO.: 3 3
�` _ /� Signature LTC.NO.: yy 33
(I,fappZicable, erfr'er exempt"an the license number line.) p
Address: Bu .r�1 Z 2
*Per M.G.L. c.147,s.57-61,security work requires Department of public Safe "S"Licen Alt'Tel.No.:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability LIC.NO.:
required by law. $y my signature below,I hereby waive this requirement. I am the(check one)El owner
normally
Owner/Agent ❑owner's agent.
Signature Telephone No.
$ f�ZMFEE:
ELECTRICAL PERMIT NO. INSPECTION REPORT: -•
ELECTRICAL INSPECTOR-DOUG SMALL
FLROUGH INSPECTION:
—[ Failed—[ ] Re-inspection required($50.00)-tors' comments:
(Inspectors'Signature-no initials) Cv 3 Date 3 Z f
2.FINAL INSPECTION:
Passed— ' Failed—[ ] Re-inspection required($50.00)-[ ]
Inspectors'comments:
(Insp ctors'Sign ure-n i itials) Date
3.UNDER GROUND INSPECTION:
Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ]
Inspectors'comments:
(Inspectors'Signature-no initials) Date r
4.INSPECTION—SER CE:
DATE CALLED N ONAL GRID: NAME:
Passed—[` Failed—[ ] Re-inspection required($50.00)-[ ]
Inspectors' comments:
(Inspectors'Signature-no initials) �h/ (v/��i Date
5.INSPECTION-OTHER:
Passed—[ ] Failed—[ j Re-inspection required($50.00)-[ ]
Inspectors' comments:
i
(Inspectors'Signature-no initials) Date
DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED.
The Commonwealth of Massachusetts
Department of Industrial.Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dia
'workers' Compensation Insuralaee Affidavit: Builders/Coutraciors)Electriciansiplumbers
Applicant Information. Please Print Legibbr
Name(Business/Organization/Individual): ,
Address:
City/State/Zip: Phone#:
A
rean employer?Check the appropriate box: Type of project(required):
a employer with 4. ❑ I am a general contractor and I 6. []New construction
loyees(full and/orpart-time).* have hired the sub-contractors
a sole proprietor or parfzier- listed on the attached sheet.r 7. ❑Remodeling .
and have no employees These sub-contractors have 8. ❑Demolition
king for me in any capacity. workers'comp.insurance. 9. ❑Building addition
workers'comp,insurance 5. ❑ We are a corporation and its
10. Elec 'caired.] officers have exercised their ❑ ixi 1 repairs ox additions
a homeowner:doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
lf.[No workers'comp. c.152,§1(4);and we have no 1211Roofrepairs
ance required.]t employees.[No workers' 13.❑Other
comp.insurance required.]
?Any applicant that checks box#1 must also Ell out the section below showing their workers'compensation policy information.
7 Homeoryners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
Icontractors 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 emptoyee. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
rob 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
X do hereby cert under the pains andpenaldes ofperjury that the information provided above is true and correct.
S. ignature: Date
EEO
onbz. Do not write in this area,to be comptefed by city or town official.
n: Permuit/License#
ority(circle one):
of a(
2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PlumbingYuspector
som Phone#:
0027 41 - 12
Date..................................
+ TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....... ........ .......................................................
has permission to perform ........ . ........f!...........:5;........................
wiringin the building of ............. ............................
.....
.......A�4.......:2 Y....d.71. North Andovei,Mass.
Fee....... Lic.Nqef .,PV. ...................
Check # 2
-Commonwealth of Massachusetts Official Use Only
` Department of Fire Services Permit No. 1002--7
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 NEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:_
City or Town of: NORTH 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) � 3 Arz
Y � --, ,1- c �-
Owner or Tenant t s e ti/_ Telephone No.
Owner's Address �r tt I n /7 & a
Is this permit in conjunction with a building permit? Yes ❑ Not—(Check Appropriate Box)
Purpose of Building .-� r/v. c Utility Authorization No. �� �y 9O
Existing Service Amps /--Z--Volts Overhead ❑ Undgrd❑ No.of Meters
New Service Amps /Zv/z Ie Volts Overhead❑ Und rd 9
g No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion of thefollowin 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 mergency ig tmg
rnd. rnd. ❑ Batte 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. TotaTons No.of Alerting Devices
No.of Waste Disposers Heat Pump Number...Tons NW.......... No.of Self-Contained
Totals: ""' Detection/Alertin Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal
Connection El Other
No.of Dryers Heating Appliances KW Security Systems:*
No.of WaterNo. f No.of Devices or E uivalent
o
Heaters KW of
Ballasts Data Wiring:
No,of Devices or E uivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
OTHER:
No.of Devices or E uivalent
Attach additional detail if desired or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: V—/i --// 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 Covera m force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the in mation on this application is true and complete.
FIRM NAME: /,2, 4 ,-, ti // 4- LIC.NO.: I J3
Licensee: s / 5,�. , �'Signatur
(If applicable, ter "exempt"in the license number line.) Ly��jO"
Address: Bus.Te1.No.: T77 zzI
*Per M.G.L c. 147,s.57-61,security work requires Department of Public Safet "S"License: Alt. c.No.:yl.
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 EJ owner's agent.
Owner/Agent
riG
Signature Telephone No. PERMIT FEE. ,$ SS /�
ELECTRICAL PERMIT NO.
INSPECTION REPORT:
ELECTRICAL INSPECTOR -DOUG SMALL
Y.ROUGH INSPECTION:
Passed—r j Failed—[ ] Re-inspection regv irecT($50.00)-[ j
Inspectors'comments:
(Inspectors'Signature-no initials) Date
Z.FINAL INSPECTION;
Passed—[ ] Failed—[ .j Re-inspection required($50.00)
Inspectors'comments:
(Inspectors'Signature-no initials)
Date
3.UNDER-GROUND INSPECTION.
Passed—[ j Failed—[ ] Re-inspection required($50.00)-[ j
Inspectors'comments:
(Inspectors'Signature-no initials)
- Date
4.INSPECTION—SERVICE: -
DATE CALLED NATIONAL GRID: NAME:
Passed— Failed—[ ] Re-inspection required($50.00)
Inspect rs'comments:
/,
(Inspectors'Signature-no ini als)
Date
• I
5.INSPECTION-OTHER:
Passed—[ ] Failed—[ ] Re-inspection required($50.00)
raspectors' comments:
'Signature-no initials) Date
-b 0 O TAGS ARE TO BE FILLED OUT AND LEFT ON SITE 7F T$Ei AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. F-1 New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached shget. 1 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. 9. ❑Building addition
t. [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.❑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' 13.0 Other
comp.insurance required.]
*Any applicant that checks box#1 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 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.#: Expiration 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 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 and penalties of perjury that the information provided above is true and correct.
Signature: Date:
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#"
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 4�
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
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia