HomeMy WebLinkAboutMiscellaneous - 230 WINTER STREET 4/30/2018Gerald Brown
Inspector of Buildings
1600 Osgood Street
Building 20, Suite 2035
North Andover, MA 01845
Claim Number:
Policy Number:
Company Name:
Date of Loss:
Insured:
Property Location:
033591296
26161400004
Arbella Mutual Insurance Company
2/14/2015
Eoin Mccann
230 Winter Street
North Andover, MA 01845
To Whom It May Concern:
Claim has been made involving loss, damage, or destruction of the above captioned property,
which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6,
to be applicable.
If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please
direct it to the attention of the writer. Kindly include a reference to the captioned insured,
location, date of loss and claim number.
Very truly yours,
Arbella Mutual Insurance Company
PO Box 699225
Quincy, MA 02269
CC: City/Town Fire Dept, City/Town Health Dept
Date .1.2,..�.1�.�-Z, .
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....'�R. , J'n,. h
has permission to perform. Re.O.J.el..��a... (, G�✓
wiring in the building of ..` .(�._. .�► ................ i .... .
at .. . ? North Andover, Mass.
Fee Lic. No. 11 ? °I... 1N4ID ......VtE-4-
ELECTRICAL INSPECTOR
Check #
11301
2012 Massachusetts Electrical Code Amendments 527 CMA 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 throughoutthe Commonwealth, and applications shall be filed' a
bn the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. 01 c. 166, § 32, an
electrical permit shall be issued to the person, fur or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L. ' e
Permits shallbe limited as to the time of ongoing construction. activity, and may be.deemed_by-the Jnspector-of_Wires abandoned-and-invalid i£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
purpose by establishing an automatic four-year extension to certaispermits -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: /Sr dote: Reapply for new permitk�-'
❑ Permit Extension .tact —Perm* ate Closed:
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 11,30-1
Occupancy and Fee Checked
[Rev. 1/071 (leave blank
APPLICATION FOR PERMIT T.,O PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code C , 527 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL INFORAUTIOA9 Date: - 1 l
City or Town of. NORTH ANDOVER To the In pec or of Wires:
By this application the undersigned gives notice of -his or her intention to perform the electrical work described below.
Location (Street & Number) 0D 14)
Owner or Tenant
Owner's Address
Telephone No.
Is this permit in conjunction with a building permit? Yes .j No ❑ (Check Appropriate Box)
Purpose of Building A440 Ps6hfW14 law, Q Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑
New Service Amps / Volts Overhead ❑ Undgrd ❑
No. of Meters
No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: /T►r �y-i►fly»v0 �--�, ,� �,g
Comnletion ofthe following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil,Susp. (Paddle) Fans ® v
TransTotal
Trsformers KVA
No. of Luminaire Outlets
No, of Hot Tubsp
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- ❑
rnd. grnd.
No. of Emergency.Lightift
Battery Units
No. of Receptacle Outlets /
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of SwitchesNo.
of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Tons Tot
No. of Alerting Devices
No. of Waste Disposers
p
Heat Pump
Totals:
Number
Tons
KW _
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal EJ Other
Connection
No. of Dryers f
Heating Appliances KW
Security
o Dev ices or Equivalent
No. of Water
Heaters KW o
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or E uivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Mres.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 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 R BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete.
FIItM NAME:. D LTC. NO.: 01) L31 --i9
Licensee: t Signaturq6Zb, LIC. NO.: /Zi
(If applicable, enter "exempt" in the license tuber line.) Bus. Tel. No..
Address: 9- Z i fe, J. d4/ AL 01960 Alt. Tel. No.:
*Per M.G.L c. Ps7 .57-61, security work requires D artment 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.
❑ 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 k`f
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 4 ti
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if 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
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass I
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass IN
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass M
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH SPECTION:
Pass '
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
z- 1-3 1
Inspectors Signa ure:
Date:
FINAL, INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com
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
Name (Business/Organizatibn/Individual):
City/State/Zip: 61540 Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ElI am a general contractor and I
r employees (full and/or part-time).*
2, 1 am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet. $
ship and have no employees
These sub -contractors have
working for me in 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. 152, §1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7ARemodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
1111 Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
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-contractbrs and their workers' comp. policy information.
am anwinployer that is providing workers' compensation insurance for my employees. Below is the policy and job site
xformalion. ,
isurance, Company Name:
olicy # or Self -ins. Lic. #:,
:)b Site
Expiration Date:
City/State/Zip:
Atach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne 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
Cup to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
ivestigations of the DIA for insurance coverage verification.
do hereby certi under the pains and penalties of perjury that the information providedabppve is true and correct.
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 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
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. # 617-7274900 ext 406 or. 1 -877 -MASSA -FE
II evised 5-26-05
Fax # 617-727-7749
WWW mace vnv/dia
N2 9689 Date. 11?e/z— -
TOWN OF NORTH ANDOVER
0 PERMIT FOR PLUMBING
,SSAcm
This certifies that ............
has permission to perform
........................
plumb' tt}he buildings of
at ...North Andover, ass.
��? ..... ..
,r
Fee .Z!P� Lic. No ...... 37/ . . ...
2& 1 2-- PLUMBING INSPECTOR
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
'
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-
CITY �/ .. I MA DATE ff 79LL11 PERMIT # 9 4 g
JOBSITE ADDRESS �� G 0_d��P� c }-,� �' ( OWNER'S NAME
P
OWNER ADDRESS _ I TEL
TYPE OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL
PRINT
CLEARLY
NEW: RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES NO
FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM _ — ( . __..._._i __. _ [--.......__. � I (_...__..___{ ___....._ ( __...__�I _1 ..........I
DEDICATED GRAY WATER SYSTEM [ -_ T ( 1== ___ (
DEDICATED WATER RECYCLE SYSTEM _ ___..__..1 .-_-..._.._f 1 .....__.__J _...._.__...I I ._.._._.-_.I
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER - (l i ( .._._-.._A I
FLOOR /AREA DRAIN
INTERCEPTOR (INTERIOR) I .__._i ; i 1
KITCHEN SINK
LAVATORYI
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL .... ........ J===== ___......._I ._.._._[ ......
IVASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
,WATER PIPING
OTHER -_! .-_._
{G
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES �E 'NO
OF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 0 AGENT
SIGNATURE OF OWNER OR AGENT
G 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.
PLUMBER'S NAME -.-,- I LICENSE # _ _ 1 SIGNATURE
MP% JP CORPORATION W# ( PARTNERSHIP O# F LLC Ek
COMPANY NAME 5�7 c .ijADDRESS
CITY STATE ZIP
FAX CELL -_Sc.1 EMAIL
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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
Name (Business/Organization/Individual):
Address:
C/
City/State/Zip:,,hrg, t!& y Al+ Q if y S Phone #: S- E% y` / 2 ZU F
Are you an employer? Check the appropriate box:
1. bT I am a employer with 4—
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2. ❑ 1 am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet. t
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
3. ❑ 1 am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
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
1 - 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.
1Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
%reformation.
[nsurance Company Name: lv G c12a cv,
?
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
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
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Date....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....... tc^'................................
has - permission to perform .r&' R -0.0.e?"^ .........................................
/ 4 x -
wiring in the building of j(I /f17W .....tvl "- '4
......................" ................................
at ... cP-?O .... .......................... . North Andover, Mass.
Fee .... Lic. No.. -illi INS WrOR
Check #
7513
Commonwealth of Massachusetts Official Use Only
- Department of Fire Services Permit No. �� G `3
Occupancy and Fee Checkeds-6 �
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: 7 /® . O 7
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&2 (amu l'NI-er
Owner or Tenant g6%FJ,��Q W . 1 ,,, A.
Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes � No ❑ (Check Appropriate Box)
Purpose of Building ¢, (.�, h �/ e� /yO 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:
Completion nfthe feWnuvino tnhlo mn„ {.n ,. oa h,, itio i— ,..tn.. „s uir..,,..
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 E-] In-
rnd. rnd. ❑
o. o Emergency Lighting
Battery Units
No. of Receptacle Outlets 6
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
Tons
No. of Alerting Devices
g
No. of Waste Disposers
Heat Pump
Totals:
Number
Tons
KW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal EJ Other
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 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: Qj(J0 . OZS (When required by municipal policy.)
Work to Start: A 6 W 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 cover a is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
[certify, under the pains and penalties ofperjury, that the information on this application is true and complete.
FIRM NAME: D ttl-j , spkyL E-- / e—e J r i L LIC. NO.: :21 C
Licensee: J4DVJ-1-t �;- 04 v4 �j Signature �j:'� — LIC. NO.: -216X
(I
6 i< -
(If applicable, enter "exempt - in the license number line.) Bus. Tel. No .4172 2 t-
Address: 23 NUS S- - It ey"'r-P /+,�1 V- 2`( Alt. Tel. No.:
*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
Signature Telephone No. FPERMIT FEE: $ �=
V"k
i
�a
quired
�A
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
UT
600 Washington Street
Boston, AL4 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Name (Business/Organization/Individual):
M
Please Print Le ibl
Address: r
4
City/State/Zip:121tsj /`�,- aQne.M
Are you an employer? Check the appropriate box:
I. ❑ I a employer with
4. 0 I am a general contractor and IP7.
of project (required):.
mployees (full and/or part-time).+
have hired the sub -contractors
New construction
2. I am a sole proprietor or partner-
ship and have no employees
listed on the attached sheet.
These sub -contractors have
Remodeling
working for me in any capacity.
employees and have workers'
g' ED Demo hon
•I [No workers' comp. insurance
comp. insurance.t
9- riding addition
3. ❑required.]
I am a homeowner doing all work
5. ❑ We are a corporation and its
officers have exercised their
10.❑ Electrical repairs or additions
myself [No workers' comp.
right of exemption per MGL
I I.0 Plumbing repairs or additions
insurance required.] t
c. 152, § 1(4), and we have no
12.0 Roof repairs
employees. [No workers'
13.0 Other
D. insurance re
]
Any applicant that checks box #1 nwst also fill out the section below showing their workers' cornpensatiopolicy infommtion
I
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 subcontractors and state whether. w not those indicating
entitiesti have
employees. If the subcontractors have employees, they must provide their workers
' comp. policy number.
I am an employer that is providing workers' compensation insurance
information. for my employees Below is the policy and job site
Insurance Company Name:
Policy # or Self -ins. Lic. M
Expiration Date:
Job Site Address:
i 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 ce MYunder the pains and penalties of perjury that the information provided above is true and correct
Si tore:
Date• ` (J
Phone #:
Official use only. Do not write in this area, to be completed y dty or town officla[
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: -
Phone #: