Loading...
HomeMy WebLinkAboutMiscellaneous - 247 FARNUM STREET 4/30/2018I 6--1 Date ... %�� . ............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that........................................................... ..... �v,q /C/ ................ has permission to perform ..... wiringin the buildingof .................................................................................... at ... "7„ „*7`}�Q,ty t -t .�,�„ � ...... , North Andover, Mass. Fee .... .-�J.. "`......... Lic. No. .................................................................................... g E CTRICALINSPECTOR Check # 7 28v�-f 2 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. �.� �p 7— Occupancy Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CodeC), 27 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: bo 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) -) & y j.:�-w s Owner or Tenant ",,y'� I&,7" i Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building;,)7)eti 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: LL -1 �qI6 Arcs �'+ A,4acx, atL�J � Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: 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- ❑N0-707Emergency Lighting rnd. grnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I 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 3 No. of 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 E] other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP - Telecommunications Wiring: No. of Devices or E uivalent OTHER: Cra Attach additional detail if desired, or as required by the Inspector of Wires. Estimated ValACURAGE: ec ical Work: b y (When required by municipal policy.) Work to Start:© Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE 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 is . force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Kr BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: LIC. NO. -.4 Csa It-,_ Licensee: ignature LIC. NO. (If applicabl nter "exempt" in the license number lingd, w � ,� ,� Bus. Tel. No.:- Address: o.• Address: �.0t Alt. Tel. No.: -Q� *Per M.G.L c. 147, s. 51-61, security work requires Department ofPublic 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) [l owner []owner's agent. Owner/Agent PERMIT FEE: $i 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 y 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 t electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible fror the V 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 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass IN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass �// Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: K r / Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com 0 0 The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, AM 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):�ll�-C� Address: A,,p City/State/Zip: Are you a mployer? Check the appropriate box: 1. am a employer with _employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. Q I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6. Q We are a corporation aand its officers. have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] 71' Type of project (required): 7. ❑ New construction 8. B44emodelirig 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12.0 Plumbing repairs or additions 13.0 Roof repairs 14.0 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 -contractors and state whether or not those entities have employees. If the sub -contractors have employees, 'they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: Ls, Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address:_ %�, �FAK/,� `D „ City/State/Zip: A,,_,_JpV ©(. 'ys_ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage ver]fication. I do hereby certif.h under the pains and penalties of perjufy that the information provided above is true and correct. Phone #: T2 �c �5 7 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # nFRI, 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 #: 0 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia i +-�' � a � � _—._ J / ' f i r t , / i 1 �{ase L -s Q Date ..... �`$..�.,. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .'t.. r.I........ .. ` ^............................................................. has permission to perform wirin in the building of``i... if.N.-.9 b` N "t.......... North Andover, ass. at .......................................... ............................ Fee .. � �...... Lic. No. �'.y........ ........... .............. t ELECTRICAL INSPECTO Check #� 12321 y -k *�5 - I q yr 1 I -]+ cal Ile Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Of''fi')cial Use Only Permit No. Iy � 0 Occupancy and Fee Checked ,[Rev- 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NMC), 527 CMR 12.00 (PLEASE PRINT MINK OR TYPE ALL MFORMATIOA9 Date: City or Town of: NORTH ANDOVER To theIn pector of fires: By this application the undersigned gives notice of his rintention to perform the electrical work described below. Location (Street & Number) /3F -0022- Owner or Tenant Telephone No. Owner's Address ` Is this permit in conjunction with a building permit? Yes E�r No ❑ (Check Appro riate Box) ` Purpose of Building Utility Authorization No. ' 017 Existing Service /O6% Amps192 7 Volts Overhead''— Undgrd ❑ No. of Meters New Service 2 00 Amps O/ Z (tOVolts Overhead E9-'--Undgrd ❑ No. of Meters Number of Feeders and Ampacity and Electrical Work: l pi f; r, Z, 3 P4-1 Ir- DD k46 -4 - Completion of the following table m be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: 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- F1 No—.-oTEmergency Lighting rnd, gmd. 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. Total Tons No. of Alerting Devices No. of Waste Dis posers p Heat Pump Totals: Number ' ' ' ' ' ' Tons ' ' KW """ " No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of YYires. 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 ❑ BOND ❑ OTHER ❑ (Specify:) X certify, under the pai ndpenal 'sof. jury that e information on this application is true and complete. FIRM NAME:. LIC. NO.:%D�, Licensee:N14�7, t` Signature, MC.(Ifapplicabe -'in the license numberline.) Bus.Tel.NAddress: i (v ( (moi C +� cG� S ,i0C���At. Tel. No *Per M.G. 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: $ %D 9 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 X r 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 r electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsiblerfor the a 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 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP CTION: Pass Failed R - Inspection Required ($.) ❑ Inspectors Comments: Masi ew 1-4US-F- IV Inspectors Signature: Date: FINAL INSPECTION: Pass IN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com It The Commonwealth ofMassachusetts Department oflndustriqlAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le0bly Name (Business/Organization/tndividual): 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. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors + �• Remodeling 2111 am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its ME] Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c.152, 1(4), and we have no §12. Roofre airs E] p insurance required.) q a 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. Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit a new affidavit indicating such. tContraetors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. . lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company N 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 ofMGL o. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or oneyear 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 certlo under the pains andpenalties ofperjury 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. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone 4 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 -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 maybe submitted to the Department of Industrial Accidents for confim7 ation 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 (ifnecessary) 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: Tho Cormx>,omoalth of Massachvsotts Department of fndusidal .Accidents OBice ofInvestigatiom 600 Washingt a Street Boston? MA 021 X Z Tel, #- 617-727-4900 eyt 406 or 1-877:MASSAFE Revised 5-26-05 Fax 6X7-727-7749 VAVW Mq.q.Q anvlrl;a 1% 4 Id A Date ...... -1. ......... 6. .— —.- 7 ter.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING �I, 0 - This certifies that ......,-S1FI, ....................................................................................... has permission to perform .... 4A & . ........ ...... wiring in the kjolding of ..................... Ylvel-/ ............................................ .................. — at .....0? Z.�.7. 5!!' .......................... . North Andover, Mass. �F&;7 ............ Fee. —I -c. NoE37 ........ ELEcrRicAL INSPECTOR Check # 7 7�F 8628 v 7-7-6 )-(-fi 0 L�01Mt0/tWi O�oRCltY4�lt3 Offigal lISC�OQIy Permit No. fC - .Uipartinent o�..tin serriicm Occupancy and Fess Checked BOARD OF FIRE PREVENTION REGULATIONS ptev.1/o7] peeve blank APPLICATION FOR. PERMIT TO PERFORM ELECTRICAL WORK AU work mbe pwf mW in memima with me M M=&iW Cuda (MEC). 5n OMt lz oo (PI.F.ASEPRIM'DVDVKORnTBAURff0N&170VVj Date: City or Town of RUr4h Pn . 6 frei To the Inspector of X bw- By this application the undaaaigned gives notice of his or her intent to perform the electrical work described below. Location (Street & Number) , V LJy 1$Fa r -n d M,4::3:4 r 0f4 d— Owner or Tenant Telephone No. Owner's Address ' Z5 q m e- . < � —• h 9--Z. — y33 is this permit in conjunction with a bnnitdiag permit? Yen ❑ No ❑ (Check Appropriate Bar) Purpose of Building �C' d� �� Utility AuthorbAtion No. Existing Service Amps 1= Volta Overhead [I Undgrd ❑ No. of Maters_ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampscity Locado and Nature of Proposed Electrical Work: - r efq",&WeXT Co ofdte f&%w1w rabk awv be vairby the Itttneear ofiYfr r No: of Recessed Lumhhairea No. of Cell. sosp. (Paddle) Fans. Tr of sformass KVA No. of Luminaire Outlets No. of Hot Tubs Generators ICVA No. of Luminaires Above Swimming Pool d. d. ❑Batter o. y Unita No. of Receptacle.Outlets 0. of Oil B ALARMS No. of Zones No. of Switches .. No. of Gras Burners n and o. o - Devices No. of Ranges Total No. of Air Cond. Tons o. of Alerting Devices . No. of Waste Dispeaers Number- ons AM No. of SOPMEER DdectloptAi Devices No. of Dishwashers SpmdAren Elenting ]!CW LocalOConn n ❑ Other No. of Dryers Hamdng Applisna s• iCW No. of . or 19guhWeirt o. o Water KWsigns o. o aI. - - Data Wiring: Heaters No. of Devices or ulvalent No. Hydromassage Bathtubs Ivo. of Motors ?� -No. of Devices a eut OTHER:: '76 4rwR+uuuun"v "c "J"WrJeW W - us 1wWw"u my ane J"WP Wr-aJ ffff= $stinuod Value �°f, Electieal Wade -57-5'. Ot (Wb by �� policy) Work to start' L.�(3Mel� bopectimstDbe requested in aacardence with MEC Rule 10, agdupon completion. INSURAN& COVERAGE: Unless waived by the owner, no permit for the performance of electrical wort may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its subsmntial equivalent The undersigned certifies that such fours rs and has exbibite d proof of same to the permit issuing office. CHECK ONE: INSURANCE rBONnrs ar ❑ OnM O (sleCifr) � Le I- t C -h .1n3 Ll rq n C�. I certih►, under the parr;crtd penalties ofp , that the info on application is tree mid rnmplete FIRM NAME: `- e o rr LIC. NO.: Licensee: Signature_ LIC. NO: (Ifopptfeablk enter" ncettse man ) , �C fa �f Bus. Tel. No - _ Address: ., e / Alt Tel. Ne.:��— 7�3y *Per M.C.L. c. 147, s. 57-61, security work requires Departmwt of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not how the liability insarancx coverage norm* required by law. By my signature below. IF hereby waive this requirement- I am the (check one', 0 owner 0 owner's agent Signature uAgent Telephone No. 'FEE. 5 Date........... . ................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ,eThis certifies that ........ .......................... ........ . .......... .................... T has permission for gasiystallation, ................ (.,.... .�*.e-- I, ........... ........ in the buildings of- . UNle . . . ........ .............. at .......... lz�,/ �t I ... &�.yn ............. ........ . North Andover, Mass. ........... . .............. 7TI*,.0 .'2101a Lic. No.... . ....... ..................................................................... Fee ....................... GAS INSPECTOR Check It k The Commonwealth of Massachusetts Department of IndustrialAceldents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: /&6J4 City/State/Zip: d A�4 616LIj Phone #: q2e " 3,7a l pl '7 Are you an employer? Check the appropriate box: 1. m a employer with__ employees (full and/or part-time).* 2.❑ I am a sole proprietor or partnership 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 4.I] I am a homeowner and will be hiring contractors to conduct all work on my -property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.I] I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6.Q 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): 7. E] New construction 8. F1 Remodeling 9. ❑ Demolition 10 Building addition 11.0 Electrical repairs or additions 12. F] Plumbing repairs or additions 13. E] Roof repairs 14.0 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 state whether or not those entities have employees. If the sub -contractors have employ ees,they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' .below is the policy and job site information. ^ J Insurance Company Name: A44 a n /l �x Policy # or Self ins. Lic. #: /0 d7�ZU_8' Expiration Date: Job Site Address: pV 7 4-61-na zYj City/State/Zipk Ar 1 0 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. 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. 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 -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 burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 4�� 10424 I This certifies that .......M... .......... Date ..;�.[, lj.t� .... . .... TOWN OF NORTH ANDOVER. has permission to perform.... -R.' plumbing in the buildings of at... ................ Fee.120.bo .. Lic. No. IS't,�'... Check # a -D PERMIT FOR PLUMBING D,e-(,Pc,s ............................................ ..................... r ................. (4-.4.4C7F ..... North Andover, Mass. M,1k .............................................. PLUMBING INSPECTOR P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY . NORTH ANDOVERMA DATE 315114 PERMIT # ►v�'I cam- - JOBSITE ADDRESS 247 FARNUM ST OWNER'S NAME HART OWNER ADDRESS L TEL FAX OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL NEW: E3 RENOVATION: El REPLACEMENT: FIXTURES Z FLOOR— BSM BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTER KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHERm___,... RESIDENTIAL PLANS SUBMITTED: YES []- N0[] m0®®m INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [:1] OTHER TYPE OF INDEMNITY IE] BOND E] 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 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc ate 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 w' I P ' ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME MIKE CAPELESS V LICENSE # X5851 IGNA URE MPEJ ip El CORPORATION#PARTNERSHIP# LLC #... COMPANY NAME THE BOILER GUY ADDRESS 160A PLEASANT ST CITY NORTH ANDOVERSTATE MA ZIP 01845 TEL 978 382 1017 FAX CELL EMAIL.._. 9 I- CGpom,0NWEALTH C F M, ASS ACEkS PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER MICHAEL N CAPELESS 105 TYLER ST 11ETHUEN MA 01844-:1905 15851 05/01/.14 1763713 ACC?Rb® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) ``/ 03/11/2014 ,,THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Matthews Insurance Agency Inc CONTACT NAME: PHONE . (978) 681-1112 FAX No : (978) 685-3855 182 Parker St MAIL EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100 000 PREMI E Ea occurrence $ ADDRESS: Lawrence, MA 01843 INSURERS AFFORDING COVERAGE NAIC # INSURERA: Atlantic Casualty GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 7 PRO LOC INSURED Michael Capeless INSURER B: Arbella 105 Tyler St AUTOMOBILE LIABILITY ANY AUTO ALL OWNEDSCHEDULED AUTOS AUTOS NED HIRED AUTOS AUTOSUTOS Methuen, MA 01844 INSURER C: HC357357 08/30/2013 INSURER D: INSURER E: BODILY INJURY (Per person) $ 300,000 INSURER F: Pe�acGtlenDAMAGE $ 300'000 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DDIYYYY LIMITS 17 GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 71 OCCUR L143000684 08/07/2013 08/07/2014 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100 000 PREMI E Ea occurrence $ MED EXP (Any one person $ 1,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 7 PRO LOC PRODUCTS -COMP/OP AGG $ 1,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNEDSCHEDULED AUTOS AUTOS NED HIRED AUTOS AUTOSUTOS HC357357 08/30/2013 08/30/2014 COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ 300,000 BODILY INJURY (Per accident) $ 300,000 Pe�acGtlenDAMAGE $ 300'000 $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 890911-0937696 02/13/2014 02/13/2015 WC STATU- I IOTH- E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100'000 E.L. DISEASE - POLICY LIMIT $ 500 ��� DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) Heating or combined heating and air conditioning systems or equipment, installation, servicing or repair, plumbing Town of North Andover North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ©1988-2010 ACORD CORPORATION. All rights reserved ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD 12/23/13 2476 Farnum Street Question from realtor. S. Sawyer response. Q: what is the maximum # of rooms allowed in this house without having to upgrade the septic system. A: The system is sized for a 3 -bedroom (330 gallon), maximum 7 -room home. It also was granted a reduction to the water table from the bottom of the septic system. For both these reasons; there shall be no increase in the design flow. When counting rooms this includes rooms such as living room, study, kitchen (eat in area included), bedrooms etc. This does not include bathrooms, non -living areas such as storage areas, unfinished attic, unfinished and/or non- occupied basement. Theoretical building addition question; To receive Health Department sign off on an application for a building permit that does not increase the home footprint; the applicant must provide a floor plan showing a maximum 7 —room home. When combining small rooms, please show any walls that are to be removed and rooms reconfigured to make 7 rooms. If there is also an expansion of the footprint; a passing title V must be submitted. 310 CMR: DEPARTMENT OF ENVIRONMENTAL PROTECTION 15.405: Contents of Local Upgrade Approval (1) In granting local upgrade approvals pursuant to 310 CMR 15.404(2) where full compliance as defined in 310 CMR 15.404(1) is not feasible, the local Approving Authority shall consider the impact of the proposed system and shall vary to the least degree necessary the requirements of 310 CMR 15.100 through 15.293 so as to allow for both the best feasible upgrade within the borders of the lot, and have the least effect on public health, safety, welfare and the environment. Under a local upgrade approval, the local Approving Authority is allowed to diverge from the goal of full compliance only to the extent necessary to achieve a feasible upgrade and may allow divergence only from those provisions, and to the extent, as specified in 310 CMR 15.404(2) and 15.405(1). In determining whether full compliance is feasible, the Approving Authority should appropriately consider not only physical possibility as dictated by the conditions of the site, but also the economic feasibility of the upgrade costs. The Approving Authority should emphasize protection of water resources and treatment of the sanitary sewage. Absent conditions which would result in a different outcome based on best professional judgment, the options set forth below should be considered in the order in which they appear with 310 CMR 15.405(1)(a) being the first option to be considered and rejected or adopted and 310 CMR 15.405(1)(k) being the last option to be considered and rejected or adopted: (a) Reduction of system location setbacks otherwise established in 310 CMR 15.211 for property lines provided that the system is within the property lines, a survey of the property line is required if a component is to be placed within five feet of the property line, and no such reduction shall result in the soil absorption system being located less than ten feet from a soil absorption system on an abutting property; (b) Reductions of system location setbacks from cellar wall, crawl space, swimming pool, or slab foundations; an increase in the maximum allowable depth of system components required by 310 CMR 15.221(7), from 36" to 72" below finish grade, provided that adequate venting and adequate access are provided and H-20 loading is provided for all system components; a decrease in the liquid depth of the septic tank required by -3 10 CMR 15.223(2) from four feet to three feet; (c) Up to a 25% reduction in the required subsurface disposal area design requirements; (d) Where upgrade is required pursuant to 310 CMR 15.303(1) because it is within Zone I of public well or within 100 feet of private well, relocation of the well. Any relocation of a public well shall be performed pursuant to 310 CMR 22.00 (water supply source approval);. (e) Reduction of system location setbacks from bordering vegetated wetlands; (f) Reduction of system location setbacks from surface waters, salt marshes, inland and coastal banks, certified vernal pools in accordance with 310 CMR 15.211(1)[21, leaching catch basins, dry wells, or surface or subsurface drains other than those which discharge to surface water supplies or tributaries thereto; (g) Reduction of system location setbacks from water supply lines, private water supply wells (but not within 50 feet of the well), tributaries to surface water supplies, surface water supplies, but not within 100 feet of the surface water supply or tributary thereto or open, surface or subsurface drains which discharge to surface water supplies or tributaries thereto; (h) the local Approving Authority may reduce the required four foot separation (in soils with a recorded percolation rate of more than two minutes per inch) or the required five foot separation (in soils with a recorded percolation rate of two minutes or less per inch) between the bottom of the soil absorption system and the high groundwater elevation only if all of the following conditions are met: 1. An approved Soil Evaluator who is a member or agent of the local Approving Authority determines the high groundwater elevation. 2. A minimum three foot separation (in soils with a recorded percolation rate of more than two minutes per inch) or a minimum four foot separation (in soils with a recorded percolation rate of two minutes or less per inch) between the bottom of the soil absorption system and the high groundwater elevation is maintained. '3. The system is a failed or non -conforming system serving an existing building with a design flow of less than 2,000 gpd. 4. No increase in design flow is allowed. 5. No reduction in required soil absorption system size or setbacks from public or private wells, bordering vegetated wetlands, surface waters, salt marshes, coastal banks, certified vernal pools, water supply lines, surface water supplies or tributaries to surface water supplies, or drains which discharge to surface water supplies or their tributaries, is allowed. 9/22/06 (Effective 4/21/06) - corrected 310 CMR - 563