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HomeMy WebLinkAboutMiscellaneous - 250 CHESTNUT STREET 4/30/2018N_ pO_ 61 O 0 N S O O O Date .......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING -?-A r�, 0 ,\ C t I r, Thiscertifies that .............. i . ........................... ................................................................ .... ... ..... has permission to perform ......... 1.1-..Lj .......................... wiring in the building of ...... ..... .... at......................................................................................................... . North Andover, Mass. FeO.2..C5 .............. Lic. No. ... .................................................................................... .. .... ...... ELECTRICAL INSPECTOR Check # t� C1nL9Wnwealth o/ aascsc�uaefia Official Use my 9J ..UeParltneni o�,}ir¢ �ervicee Permit No. 5 BOARD OF FIRE PREVENTION REGULATIONS Rev. l%7cy and Fee Checked leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(r 2,11 C i 2.00 (PLEASE PRINT W INK OR TYP O TI N) Date: I City or Town of: To the Inspector o Wires: By this application the undersign s once o o r ' entio to pe orm the electrical work described below. Location (Street & Nu er) Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Bog) Purpose of Building oil �p _ - tO M I IA J M Utility Authorization No. Existing Service � Amps [aD / 64D 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: I nQ,.r'll k1 a..., ..., ANC Com letion o theollowina t be l • b Attach aawttonal detail tj-desired, or as required by the Inspector of Wires. Estimated Value Ele I Work: L (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 liabili insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such c erage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCYO BOND ❑ OTHER ❑ (Specify:) I cerh; fy, under the pains and penalties of perjury, that the information on this application is nd complete. FIRM NAME: 11(1 �( LIC. NO.,: �a, � Licensee: Zam k� Signature,,LIC. NO.:�J 1-1 I A- (Ifappltcabl ,enter ` empt" in the lice a number line.) Bus. Tel. No.:ISI - J Address: S Alt. Tel. No.:SQ1-4-1`4q •��raa *Per M.G.L. c. 147, s. 57-6 , security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANC R: I am�aware that the: Licensee-doesnot-have theliability-insurance coverage normally - required by law. By m igna . below, I hereby waive this requirement. lam the (check one owner ❑ owner's nt. Owner/Agent Signature Telephone No. (2 a � PERMIT FEE: $ m a waroed b the !ns ctor ot Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans o' or Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above e [Dd, ❑ Emergency g gruts Banor e No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection an Initiatin Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers eat Pump Totals:.._......... umK .. ons -` ` " o. o e - ontam Detection/Alertiner Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal❑ Other Connection No. of Dryers Heating Appliances Kir SecuritySy—stems: No. Devices No. o Heaters KW atero. St Ballasts No. ofData of or Equivalent Wiring: No. of Devices or Eauivalent No. Hydromassage Bathtubs No. of Motors Total HPTe-Te—co mm caponsum No. of Devices or E uivalent OTHER: Attach aawttonal detail tj-desired, or as required by the Inspector of Wires. Estimated Value Ele I Work: L (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 liabili insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such c erage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCYO BOND ❑ OTHER ❑ (Specify:) I cerh; fy, under the pains and penalties of perjury, that the information on this application is nd complete. FIRM NAME: 11(1 �( LIC. NO.,: �a, � Licensee: Zam k� Signature,,LIC. NO.:�J 1-1 I A- (Ifappltcabl ,enter ` empt" in the lice a number line.) Bus. Tel. No.:ISI - J Address: S Alt. Tel. No.:SQ1-4-1`4q •��raa *Per M.G.L. c. 147, s. 57-6 , security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANC R: I am�aware that the: Licensee-doesnot-have theliability-insurance coverage normally - required by law. By m igna . below, I hereby waive this requirement. lam the (check one owner ❑ owner's nt. Owner/Agent Signature Telephone No. (2 a � PERMIT FEE: $ a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations UT 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly 1 Name(Business/Organization/Individual): yin t Address: '3301 Q -t LIL)X y .5114C J0G City/State/Zip: Le, t uv— V Y d g 3 Phone #: TV(- 2 L T- G1 -r S f Are you an employer? Check the appropriate box: 1. Lh I am a employer with 4. ❑ i am a general contractor and 1 employees (full and/or part-time).* have hired the sub -contractors 2. [_]I am a sole proprietor or partner- listed on the attached sheet. I 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 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof r, si . 13�'6ther _ K 'Any appltcant 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. tContractors 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 Name: N r; G, Anter—r c^ri 17 S&I '4 rn c Ga.IVwy cl Policy # or Self -ins. Lic. #: Vel t' S-0 'Y (a U / U Expiration Date: I ( i I Job Site Address: 0��&�Ui `r City/State/Zip: � ) , 4, 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 tip to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 1 1- Z- I S - Phone #: Ss'U f- Z 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 #: VIVINT SOLAR DEVELOPER LCC PHILIP F ZAMPiTELLA JR (EL) 4931 N 300 W - PROVO UT 84604 I�a1dL lh.n DSU � � pyo -k- IX)MANONVAEALTH 6L iC1A*S Z �? 1.5SUES ME FOLLOWING &TESSE AS SIIERED MASTGRALECTR1C1AN V?VfIW SOLAR DEVELOPER LLC FW I L I P I-MWMWLLA JR, 4.931 U. -"Q w Pawo ` W 84604 3 T41 .! 07%33Cit r 101. EcolibriumSolar Customer Info Name: 4665284 Email: Phone: Project Info Identifier: 52781 Street Address Line 1: 250 Chestnut St Street Address Line 2: City: North Andover State: MA Zip: 01845 Country: United States System Info Module Manufacturer: Trina Solar Module Model: TSM 260-PD05.08 Module Quantity: 40 Array Size (DC watts): 10400.0 Mounting System Manufacturer: Ecolibrium Solar Mounting System Product: EcoX Inverter Manufacturer: SolarEdge Technologies Inverter Model: SE10000A-US (240V) Project Design Variables Module Weight: 43.0 lbs Module Length: 65.0 in Module Width: 37.0 in Basic Wind Speed: 90.0 mph Ground Snow Load: 50.0 psf Seismic: 0.0 Exposure Category: B Importance Factor: II Exposure on Roof: Partially Exposed Topographic Factor: 1.0 Wind Directionality Factor: 0.85 Thermal Factor for Snow Load: 1.2 Lag Bolt Design Load - Upward: 820 Ibf Lag Bolt Design Load - Lateral: 288 Ibf EcoX Design Load - Downward: 722 Ibf EcoX Design Load - Upward: 765 Ibf EcoX Design Load - Downslope: 297 Ibf EcoX Design Load - Lateral: 233 Ibf Module Design Moment — Upward: 3655 in -Ib Module Design Moment — Downward: 3655 in -lb Effective Wind Area: 20 ft2 Min Nominal Framing Depth: 2.5 in Min Top Chord Specific Gravity: 0.42 Plane Calculations (ASCE 7-10): 1 Roof Shape: Gable Roof Type: Composition Shingle Average Roof Height: 25.0 ft Least Horizontal Dimension: 25.0 ft Roof Slope: 24.0 deg Truss Spacing: 16.0 in Snow Load Calculations Edge and Corner Dimension: 3.0 ft Stagger Attachments: Yes Include Snow Guards: No EcolibriumSolar Description Interior Edge Corner Unit Flat Roof Snow Load 42.0 42.0 42.0 psf Slope Factor 0.84 0.84 0.84 psf Roof Snow Load 35.3 35.3 35.3 psf Wind Pressure Calculations Description Interior Edge Corner Unit Net Design Wind Pressure Uplift -19.4 -31.9 -47.9 psf Net Design Wind Pressure Downforce 11.4 11.4 11.4 psf Adjustment Factor for Height and Exposure Category 1.0 1.0 1.0 psf Design Wind Pressure Uplift -19.4 -31.9 -47.9 psf Design Wind Pressure Downforce 16.0 16.0 16.0 psf ASD Load Combinations Description Interior Edge Corner Unit Dead Load 2.6 2.6 2.6 psf Snow Load 35.3 35.3 35.3 psf Downslope: Load Combination 3 14.2 14.2 14.2 psf Down: Load Combination 3 31.8 31.8 31.8 psf Down: Load Combination 5 12.0 12.0 12.0 psf Down: Load Combination 6a 31.6 31.6 31.6 psf Up: Load Combination 7 -10.2 -17.7 -27.3 psf Down Max 31.8 31.8 31.8 psf Spacing Results (Landscape) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 59.8 59.8 59.8 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 48.0 48.0 48.0 in Max Cantilever from Attachment to Perimeter of PV Array 19.9 19.9 19.9 in Spacing Results (Portrait) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 45.0 45.0 45.0 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 32.0 32.0 32.0 in Max Cantilever from Attachment to Perimeter of PV Array 15.0 15.0 15.0 in EcolibriumSolar Layout -- Skirt Coupling O Clamp Q Bonding Jumper Note: If the total width of a continuous array exceeds 35 ft, break array to allow for thermal expansion and contraction. See Installation Guide for details. Warning: PV Modules may need to be shifted with respect to roof trusses to comply with maximum allowable overhang. EcolibriumSolar Roof Mights In Conformance with Solar ABC's Expedited Permit Process Module Quantity: 40 Weight of Modules: 1720 lbs Weight of Mounting System: 150 lbs Total Plane Weight: 1870 lbs Total Plane Array Area: 668 ft2 Distributed Weight: 2.8 psf Number of Attachments: 75 Weight per Attachment Point: 25 lbs EcolibriumSolar Bill Of Materials Part Name Quantity ECO -001_101 EcoX Clamp Assembly 75 ECO -001_102 EcoX Coupling Assembly 45 ECO -001_105B EcoX Landscape Skirt Kit 10 ECO -001-105A EcoX Portrait Skirt Kit 0 ECO -001_103 EcoX Composition Attachment Kit 75 ECO -001_116 EcoX Flat -Tile Flashing 0 ECO -001_117 EcoX S -Tile Flashing 0 ECO -001_118 EcoX W -Tile Flashing 0 ECO -001_363 EcoX Lower Support - Tile 0 ECO -001_109 EcoX Electrical Assembly (optional) 1 ECO -001_106 EcoX Bonding Jumper Assembly 4 ECO -001_104 EcoX Inverter Bracket Assembly 0 ECO -001338 EcoX Connector Bracket 0 ECO_001-359 EcoX Lower Support - Low Slope 0 7I - - - - - - - - - - --1 Cn, O �< I aU I o -< I I c OK I ,--+- I c � I m I I C , V I I I ❑ Z O I I I I I I \%W I v O I J d I J I N N I � ------------ I 3 v O a 9 m;a m wiz m A Z 0 0 O m< I 0 3" A 4 0 o ❑ CCO C' �WAA m. 0 M W i m nNZm cZi< zmC O() mCZ_z nD z m�Nm O 0 m Z3 Oo 'n I r > Om,0 �om �� -Diom A 0 O oAO n m m0 I D Z Z m I ❑ � ^ I I v/-7 cn I I II m I I � cnI--i o m I I DI Z I I c2 3 m D= rn m INS TALLER:VIVINTSOLAR O Logiudice Residence INSTALLER NUMBER: 1.877.404.4129 PV 1.0 CO m SITE m �^ V V I ,1O v v U 250 Chestnut St MA LICENSE: MANIC 170848 A PLAN North Andover, MA 01845 UTILITY ACCOUNT NUMBER: 03986-67000 DRAWN BY: Matt J AR 4665284 Last Modified: 10/13/2015 am cn Z ' 0 '0 m A A < O 1 O Z1 CZ m0 w u �< 'REM \ 0/// 11 3� 1 Oz vZ = � N (7 m U) D r � m � O OD � I. m ooh °o =�� o OA`Fr 0 Ow< aO T V O 1 O -' =Z r O D �W Z c= K a= INSTALLER:VIVINTSOLAR O O ` Logiudice Residence INSTALLER NUMBER: 1.877.404.4129 PV 2.0 m m ROOF m m `f LJ V V U V O 1 250 Chestnut MA LICENSE: MAHIC 170848 A PLAN North Andover, MA 01845 0 DRAWN BY: Matt J AR 4665284 Last Modified: 10/13/2015 UTILITY ACCOUNT NUMBER: 03986-67000 • o nn DO< Z �� m-0 Dmf o 0 O �+ rn0 mho r CE ��m M m O cn __- m (n r° �n� OZ� Kz gad O� Z �o z�� mm� 00 o D0O O D-0 �l Z ZOZ mT--1 � O D W D Z C) 0 3 0 M 0 r 11 -- C) 0 3 0 D� K Dp C _U m � 0 Cl) 0 M m �! n� K 0 m 0 0 D n �� o � � C Z G' 0K0 r -D � 0� - -i Z D m -Z =+ n r Z W G) r m Z m I / G)m I \ M z 17- 0< i < < 0 -< D --I cn cn O D --IZ r M O C �CnK� O�Z- r' C -0 *� DD Z Om!� r i9 m��k Cnn n to r mZ 9 Z Xm Z �� G)cn— G) -1;0 X0 -0 G µ n D n> N ;U Z xmm N Cn D O r D r -0 n n n rC/) r n O o� K n - O r ��nm -0XZ� - D o ATO- m m D s D_ n�mp M M = C7 ZDn0 �xo� C o m O p FMK Z N O f" m ::EK W to Cn N ;: _ M i Z C = > i INSTALLER: VIVINT SOLAR INSTALLER NUMBER: 1.877.404.4129 O O ,T1, �n�l ` Logiudice Residence PV 3.0 Mm m m MOUNT. mm � MA LICENSE: MAHIC 170848 v �' u u L] O �� 250 Chestnut z DETAILS 0 1845 North Andover, BE :039 UTILITY ACCOUNT NUMBER: 03986-67000 DRAWN BY: Matt J AR 4665284 Last Modified: 10/13/2015 00 ti m0 mC) Am c2 Di INSTALLER:VIVINTSOLAR �/� O�n O/j� Lo iudice Residence ED 3 -LINE mm INSTALLER NUMBER: 1.877.404.4129 V 5 V �u u� solar g E 1.0 m I MA LICENSE: MANIC_ 170848 t� u N O �w 250 Chestnut SI T DIAGRAMNorth Andover, MA 01845 DRAWN BY: Matt J AR 4665284 Last Modfed: 10/13/2015 UTILITY ACCOUNT NUMBER: 03986-67000 •off o� nm c0 cn O 00 Z A O cnm K —1 m 0 oA� X _ r:710 CZ v>z D G7 m O m TI m 1 3 +. T�,►. 1 * 0 � n 4 s. Z 2 F m 0 ON �tJ f"i 00 0 m z to Z r mm .. mm c� Z 0 .z M, { 1 O cn m'OO O4 �O ,,,. m c A �z rm i> mo 0 W m 0 �c rD m U) C3 V> z OC cg �m -, m O c m m m m z z m DESIGN z rn INSTALLER: VIVINT SOLAR O O�^�''� C�'1 Logiudice Residence PV 4.0 K � � LOGIC mm � INSTALLER NUMBER: 1.877.404.4129 �� v v �LJ ULA] O 250 Chestnut 0 North Andover, MA 01845 MA LICENSE: MAHIC 170848 DRAWN BY: Matt J AR 4665284 Last Modified: 10/13/2015 UTILITY ACCOUNT NUMBER: 03986-67000 Date ....-��%... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ,,. .....!'.`.: C", Ae ........................................................................................... has permission to perform ............... .............. j................................................................ wiring in the building of ..... �... a,�..'�Qr... .............................................:........... at .......� .....��.....U.......... t ..�.5 //. ............ � North Andover, Mass. Fee.... 5 :........... Lic. Noa.lg1. ..................................................................................... ELECTRICAL INSPECTOR Check # l 6.or cues x � el Official Use Only P cI L�I62-i epa�Fni Q��F� �e� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code( C), 527 CWI R 12.00 (PLEASE PSV�'BN K 0R,YYPEA L JWFORW ON) Date: 2 � X� CityerTownef MofrT i-tJM-N491,T'O the InSpe ar Of "VS By this application the undersigned gives notice of his or her intention toperformthe electrical work described below. Location (Street & Number) 2-6o CA- �4—w 0-r 1 Owner or Tenant Owner's Address Telephone No.�)% r (B-[ s- 39 Is this permit in conjusefto mph a bundleg permlf? Yes " No X (CIS Appl k Purpose og kSd"W—Q , U An No, 31-3 25 Existing Service _LED Amps L 20 / gAgVoits Overhead Z Undgrd ❑- No. of Meters New Service 7,00 Amps 12-0124OVolts Overhead Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �9"-rsr►a��t,'.�ir:as�4hw fiaw T1IDsfol ofol►2a. V No. of Recessed Luminaires No. of Ce!L-Sus . addle Fans p (Paddle) r eta Transformers KVA No. of Luminaire Outlets Na of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above [] °' ❑ g nd. rnd. a o Units Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Sa ite s Nom. o&` Gi3X:Bi3rAci & a: o ecce pffi a No. of Ranges TWA No. of Air Cond. Tons o. ofAlerting Devices No. of Waste Disposers p at up Totals: min er ons o 0 ontaine Detecdon/Alerdnz Devices Na of Dishwashers Space/Area Heating KW Mun'e coon ❑ Other Local ❑ Conn No. of Dryers Heating Appliances KW ecN� of DEviC & or Equivalent- 6.- 2ter KW � No. Hydromassage Bathtubs +fl. a Ila s No. of Motors Total HP Data Wiring: 'No. of vices or Z9901eat b to r bgg" Na of Devices or E nivalent OTHER: Attacn aaamonat aerait iJ aesirea, or as reyuircu oy int: inapW-ur v,/ rr ucu. Estimated Value of Mectrical Work: Z6oc2 (When required by municipal policy.) Work to Start: 2- iX 1(o inspections to be requested in accordance with NEC Rule 10, and upon completion. INSURANCE, COV : Unless wauved: by the owner, no pesrnit for the gei f(=nance of etectrical work may issue unnItss the licensee provides proof of Liability insurm= i ling. --cwnpj-ete&-q=afiwi7 coverage or its substantial, Wit. 'Me undersigned certifies that such coverage is in force, and has exhibited proofofsame to the permit issuing office. 3 'No CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains mF d penaldfes o p u , that the information on this appl n is true and comp FIRM NAME: R. LIC. NO 2)4 Licensee: _ Signature LIC. NO.: > 4wiowk ave' "eAqpt"til tip Brae n ew liae.} lin. TeL 4 AAdm= 6 LIM AIL TVL No- *P'er RG.L. c. 147,.& 57-61, security work requires E3 putnerit of Public 'Safety "'S" License: Lit. 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 D owner's agent Owner/Agent I PERMIT FEE. $ Signature Telephone No. -a�-'Vy �2-e �j �)l V-Y)AII .. The Commonwealth of Massachusetts F Department of Industrial Accidents X Congress Street, Suite 100 ' d Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/l leciricians/Plwmbers. TO BE FILED WITHTHEPERMTTTINGAUTHORTJY. ,,1 ^^^^bM;„41 A1YPIIcanz lulus luaau.,,. Name (Business/Orgat&ation/lndividual): 6� ty37 •Art �C���1 C.. Address: � l lel l r Phone City/State/Zip:� r Are you an employer? Check the appropriate box: I am a employer with,--_ .employees (hill and/or part-time).* 29 am a sole proprietor or partnership and have no employees Working for me in ca acity [Noworkers' comp. insurance required.] ny p 3, ❑ lam 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.FJ We are a corporation and its, officers have exercised their right of exemption per MGL c. 1 4 and'we have no employees: [No workers' comp. insurance required ] Type of project ()Vequired); 7. El Nei t'ddnstructlon 8. E] R'emodeli'ng 9. ❑ Demolition 10 ❑ Building addition 11)%Elecirical repairs or additions I ; :plumbing repairs or additions 13JJ Roofrepairs 14.[l Other 152, § O, - *Any applicant that checks bbk 41 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 anew 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 (hose entities have e a ,,PPS TfAn sub -contractors have employees, they must provide their workers' comp. policy number. X am an employer that is providing workers' compensation insurauee for my employees. information. Insurance Company MWAVIORTIMAIN ,below is the policy andyob sate L �( �j5 4 �`� pixation Date, 6 ?,:2_4l Policy # or Self -ins. Lie. #: � AV L � ©©” City/State/Z Job Site Address: 2 >.p. '� Attach a copy of the yvoxkexs' 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 foie up to $1,500.00 and/or one-year imprisonment, as well shat meat may be forwarded to the office civil penalties in the form of a STOP WK O IuvOeSRtTgations of the DIA for insER and a fine of up to ur50�00 a ce day against the violator. A copy of this coverage verification. Ido hereby certify unde�tite pains andpenalties ofperjury tlaat tlae information provided above is true and correct. _ 1,,.,1 . ( VA AlCL4U.1 v. Phone #: 71?) ✓ official use only. Do not write in this area, to be completed by city or town offaciaL 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 - Phone Contact Person: 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 Mire, 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 enferprise, and including the legal representatives of a deceased employer, or the receiv&bv trustde 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 b6 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 certificates) 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 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-MASS.AFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Date Z Zs 1 Town of North Andover Your permit has been sent back to you for the following reasons: 1) Check amount incorrect 2) No copy of current license 3) insurance Binder not on file or expired 4) No Workers' Compensation Insurance Affadavit Form Please call with any questions 978-688-9545. Fax 978-688-9542 Workers' Compensation Form and Schedule of Fees can be found on the Town of North Andover Website under Building Department. Mailing Address: 1600 Osgood Street, Building 20, Suite 2035, North Andover, MA 01845 Date ....... Gj.....v........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....:,... ' �.. ti i P.........(�.' 7 t�V......................................................... :..... has permission to perform ........,..,. (.................................................. r wiring in the building of....... ..':......... ...........`..;.:.t..C............................................... at .......2.3 (�..... .... , North ndover, Mass. ........................... Fee... ........ Lic. No. ..J!?/ 9.?...... a'..`..,^......G? '............:...:....... ELECTRICAL INSPECTOR Check # 1/ y k l.,ommonwealth o f VaMachujeth Apartment of -%e Service] 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 IN INK OR TYPE ALL INFORMATION) Date: tJ - /,3-)15 City or Town of: 4L r A 10 nd60er 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) Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes ❑ Purpose of Building �.p S 1 d'PhL Q- r No ❑ (Check Appropriate Box) Utility Authorization No. Existing Service Amps / Volts Overhead ❑ New Service Amps Number of Feeders and Ampacity Location and Nature of Volts Overhead ❑ Undgrd ❑ No. of Meters Undgrd ❑ No. of Meters Electrical Work: of the following table may be waived bv the In ector of Wires. No. of Recessed Luminaires No. of Ceil: (Paddle) Fans of Total TransSusp. Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o Units Emergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Tons Tot No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: I Number. Tons KW No. of Self -Contained Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers IFieatin Appliances g pP KW Icec:ri±; Systems:* v No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring• No. of Devices or Equivalent 11\i„ T7...7 ,.,,.„.. �..,,,.,, DntI. F..I� .U. ,,ytlt uluaaaagc "atntu s 11\T,, l Motoins T..��1 IID No. o, Matta s =,tall �.. I 1 cicwullu utl la:a tiviiJ Wit -Ing: � No. of Devices or Equivalent OTHER: N Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work:go -- (When required by municipal policy.) Work to Start: inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C VE GE: ITnIess 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 unrlercionerl certifies that Inch coveraoe is in fnrc,P and has Pxhihiterl nronf n_ f c_ Prne to the nermit k nino offire. CHECK ONE: INSURANCE BONDE] OTHER ❑ (Specify:) i45 G ro U (� / certify, under the pains andpenalties of pp- rim that the information nthis application is true n and completely. FIRM NAME: t-7-4 Ju 4% ... ... M Le ac a LIC. NO.: 392 Licensee- Sienature LIC1. N0.: (Ifapplicable, enter "tempt" m he license number• line.) //I Bus. Tel. No. Address: li,ek� _V- ��Ph �a d/L 7' � Alt. Tel. No.: --?-- *Per M.G.L. c�7-61. security work rea_uires Denartment of Public Safety "S" License: Lic. No. !\\\/IU L'l.jt�l' I1VO1 D A Ai!'C \711A TAIV13. T ♦l. ♦ t1.,. T .J,.,,.. ' L....... ♦1... 1..1.'1't.. 11., V Tra\L wl 11 \e7Vl\t91.\�..V ♦1 A1. r Ll�• 1 a111 uwarC t lat lllV LtCeIIJCC LtVGJ %[Vt /ttt VG tllti 11 CLVl Ity 111J1.1ranCV CV VCragC Ilollllally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's a ent. Owner/Agent Sienature Telenhone No. PERMIT FEE: $ Cunningham Lindsey U.S., Inc. P.O. Box 703689 Dallas, TX 75370-3689 Telephone (888) 738-8714 CLCAT@CL-NA.COM Facsimile (214) 488-6766 AUTO`*3-DIGIT 018 774 T3 P1 95000058964 Building Commissioner or Inspector of Buildings 120 MAIN STREET N ANDOVER, MA 01845 Cunnin ham �% Lindsey Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS Ch. 139, Sec 3B 2088859 2088859 14 MERRIMACK MUTUAL FIRE INS ICE DAM 2/15/2015 SALVATORE & ALFREDA LOGIUDICE & ENG 250 CHESTNUT ST 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 313 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. Section 313. No insurer shall pay any claims (1) covering the loss, damage, or destructions to a building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss, damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Claim Number: Policy Number: co Company Name: 0) Cause of Loss: co Lo C> Date of Loss: Insured: 0 Property Location: Cunnin ham �% Lindsey Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS Ch. 139, Sec 3B 2088859 2088859 14 MERRIMACK MUTUAL FIRE INS ICE DAM 2/15/2015 SALVATORE & ALFREDA LOGIUDICE & ENG 250 CHESTNUT ST 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 313 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. Section 313. No insurer shall pay any claims (1) covering the loss, damage, or destructions to a building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss, damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven 6 of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this section. On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Cunningham Lindsey Catastrophe Department cicat@cl-na.com 800-867-3885 LocationTA-1U No. Date �O"'" TOWN OFFNORT'DOVER �? !�_ '* I Certificaf of Oc Pirxy $ x ,=1 %u� %,`' BuildinglFranti�rmit Fee., SS 14 sE�h Foundation Permit $ Other Permit Fee `°�$ `7 Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector. / Div. Public Works i C7 W a � a a Y 0 0 m W F - Q W N N vii d a X N M pi W W Z 3 Q Z Z W O m a 0 J = Q m W K o~t 0 0 p 0 O 0 I - Z W N N W I IL 0 w LL K N O N IL z m m 0 H c_H W (ZL t� U. 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