HomeMy WebLinkAboutMiscellaneous - 21 HIGH STREET 4/30/2018 (24)R�
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Date ... /...' .( S ....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
T,o
This certifies that ..� 7. .... f. sD�jl �c7"�..
has permission to perform ....... �!.�ta� Le9!fie .�...........................
wiring in the building of .......... `x'..:�! P .............................................
at ....� / n` �7 S.�...................................... . orth Andover, Mass.
...............................
Fee.... �.zS.. Lic.No....+�.?-�. 7�'..........................................
ELGTRIcAL INSPBCTOR
Check t1 7oc�2
;8341
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
C�NL
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 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 - tention toperform the electrical work described below.
Location (Street & Number) 9r(f
Owner or Tenant
Owner's Address
Telephone
Is this permit in conjunction with a building permit? Yes No
��A j ty ❑ (Check Appropriate Boz)
Purpose of Building i G.- t UtiliAuthorization No.
Existing Service Amps / Volts Overhead ❑ Und rd
g ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Und rd
g ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: V��1vd ;,--Ole
Cmmnlatinn nftho fnll—i— r.,1.l0 , 1,,.. ,.,7 1,. L, r_ _ ._ _rrnr____
No. of Recessed Luminaires
_ _ __
No. of Ceil: Susp. (Paddle) Fans
. y .� ..y ., t.aV/ Vl "A'uJ.
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- ❑
rnd. rnd.
o. o Emergency Lighting
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
Initiatin Dl vices
No. of Ranges
No. of Air Cond. Tons
No. of Alerting Devices X/
No. of Waste. Disposers
Heat Pump
Totals:
Number
Tons
"'
KW.
""" "'
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KWLocal
❑ Municipal ❑Other
Connection
No. of Dryers
No. of Water
Heaters KW
Heating Appliances KW
No. of No. of
Signs Ballasts
Security Systems:*
No. of Devices or Equivalent
Data Wiring:
No. of Devices or Equivalent /19
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or E uivalent /0
OTHER:
j Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: / fid® (When required by municipal policy.)
Work to Start: &I—OAVIPInspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and enaldf perjury, that the inform on this application is true and complete.
FIRM NAME: ��� LIC. NO.: /,
1 124-7
Licensee:% ,� Signature LIC. NO.'/
(If applicable, enter -"exemp,tf "� in the license r umber 1� Bus. Tel. No.:
Address: /� �! /U��,��� / `t �1 Alt, Tel. No.:
404
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. W"17
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: $
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:
S e *6-- — Phone #:
Are you an employer? Check the appropriate Vox: . ,Irl 1
1.0 I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ I am a sole proprietor or partner- Iisted on the attached sheet. $
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself [No workers' comp.
insurance required.] t
These sub -contractors have
workers' comp. insurance.
❑ We are a corporation and its
officers have exercised their
right of exemption per'MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.] -
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
I LM Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they 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: V/Q
Job Site Address:�et City/State/Zip:/�d✓�-
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 underje-s�a�ttd�penalties of perjury that the information provided above is true and correct
Phone #: ,,-,
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
9//o
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 #:
BURT 9 H ILL
October 16, 2008
Mr. Gerald Brown
Inspector of Buildings
Town of North Andover
1600 Osgood Street
North Andover, MA 01845
Re: NexAmp Phase 2 Tenant Fit -out
East Mills, North Andover
Burt Hill Project 07804.09
Dear Mr. Brown:
The tenant improvements for NexAmp Phase'2-on the second floor of Building Three, at East Mills in
North Andover, MA, were to the best ofmy-knowledge, belief, and understanding, constructed in
conformance with the construction documents issued for building permit dated August 22, 2008 Permit
# 133 in accordance with 780 CMR Commonwealth of Massachusetts building code. During the
course of construction, representatives of our office made periodic visits to the site to observe the
progress of the work.
Sincerely,
BURT HILL
Linda S. Smiley, AIA
Senior Associate
Phone: 617.654.6003
cc: Kieran Whelan
Skip Rose
Architecture Engineering Interior Design Landscape Master Planning
303 Congress Street 6'' Floor Boston MA 02210-1012
tel: 617.423.4252 fax: 617.423.4333 www.burthill.com
Date .... /L...:Z:1.... v.....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....... �f�l �/�1/S-...®rvS....���i"�,,G
has permission to perform......
.........................................................................
wiring in the building of ...................� e.rr ......
..1 ....................................
at .........�...!1��7!..5 ,.North Andover, Mass.
........................................
Fee. Z. ............. Lic. No..........1.�;,
tLECfRICAL IWSPECTOR
Check #
7883
y
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. &?
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 (MEC), 527 CMR 12.00
(PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date:
City or Town of: NORTH ANDOVER To the Inspector 4f Wires:
By this application the undersigned gives notice of Ws or her intentiva..to perform the electrical work described below.
Location (Street & Number) , V
Owner or Tenant AYAiTelephone No. 4 ✓Tyl, Ir
Owner's Address l /yW,(,V�
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of BuildingUtility 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: lU'/XI��`
Comnletinn nfthe fnllnwino tnhlo may ho u,niv 4l,o tha e. f... -fW;..,,..
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- ❑
nd. rnd.
o. o Emergency Lighting
Battery Units
No. of Receptacle Outlets r3
No, of Oil Burners
FIRE ALARMS
No. of Tones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers !
Heat Pump
Totals:
Number
Tons
KWNo.
...........
of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal F1 mer
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water
Heaters KW
No. of No. of
Signs Ballasts .
Data Wiring: /
No. of Devices or Eq uivalent
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 Electric Work: mil/ (When required by municipal policy.)
Work to Start: �i �� Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE CO RAG : 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 the pains andpenalties ofperjury, hat the innfor tion on this application is true and complete
FIRM NAME: �/1/ /��, LIC. NO.:
Licensee: g�W '0Signature LIC. NO.:
(If applicable, enter "
Ire in the e icense number linej,—, Bus. Tel. No.: 461,7 OW 11aclo
Address: Alt. Tel. No.: 4ti"7 4, 7
*Per M.G.L c. 147, s. 57-61, security work requires Department 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 PERMIT FEE: $
Signature Telephone No.
J
The Commonwealth of Massachusetts
ki ! Department of Industria! Accidents
t Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A�piicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip:
Phone #:_
Are you an employer? Check the appropriate box:
I . ❑ i am a employer with
4. ❑ I am a general contractor and I
..employees (full and/or part-time).*
have hired the sub -contractors
2I am a sole proprietor or partner-
listed on the attached sheet t
ship and. have no employees
These sub -contractors have
working for mein any capacity,
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No -workers' comp.
c. 1.52, § 1(4),' and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required).-
6.
required):6. ❑ New construction
7. ❑ Remodeling
S. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
-nny appucam mar cneeKs oox # l 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 infomtation.
1 am an employer that is providing workers' compensation insurance for my employees: Below is the policy and job site
information.
Insurance Company Name:
Policy 9 or Self -ins. Lie. #:
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 certifypdd�r the
of perjury that the information provided above is true and correct
Date-
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 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 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
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: `
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 446 or 1-8.77-MASSAFE
Revised 5-26-05
Fax # 617-727-770
www.mass.gov/dia
X71e
Date. -F
4, TOWN OF NORTH ANDOVER
0
PERMIT FORPMBING
CHU
, '4
This certifies that ........(//........ .
has permission to perform ....... .....................
plumbing in the buildings of ....
at ..... . . ..k North Andover, Mass.
..il
Fee. .... Lic. No./S—.5�/ ...7 .......... .. .........
PLUMBING INS CTOR
Check #
7617
P
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building
Skud Owners Name
Date �O
Permit # '7
Amount
Type of Occupancy
NewriRenovation Replacement Plans Submitted Yes ❑ . No
(Print or type)
Installing Company Name
Address
Name of Licensed Plumber: �Q
Insurance Coverage: Indicate the type
Liability insurance policy juju
Check one: Certificate
/ /7�D ❑ Corp.
Partner.
Firm/Co,.
'ante coverage by checking the appropriate box:
Other type of indemnity ❑ Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature IOwner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State DI mb'n ode Ad C 14 the General Laws.
By: MgM,aLure, of LICC,iacu rIUMDer
Type of Plumbing License
Title 16-1 y 7
City/Town cense um er Master Journeyman ❑
APPROVED (OFFICE USE ONLY
i
--O----..MMMWMWMWMWMMWMMMMWWMMMM
-------.--�-..-�
mom
J 1 •6 '
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W..,1 •4'
-...-----.--O--..-----.-.E
MMMWMMMMMMMMMWMMMMMMWMNW
W131"IDUT."M
MMWM00MMMMMMWMMMMMMWWNMMM
(Print or type)
Installing Company Name
Address
Name of Licensed Plumber: �Q
Insurance Coverage: Indicate the type
Liability insurance policy juju
Check one: Certificate
/ /7�D ❑ Corp.
Partner.
Firm/Co,.
'ante coverage by checking the appropriate box:
Other type of indemnity ❑ Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature IOwner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State DI mb'n ode Ad C 14 the General Laws.
By: MgM,aLure, of LICC,iacu rIUMDer
Type of Plumbing License
Title 16-1 y 7
City/Town cense um er Master Journeyman ❑
APPROVED (OFFICE USE ONLY