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HomeMy WebLinkAboutMiscellaneous - 255 MASSACHUSETTS AVENUE 4/30/2018 (2)Ntp, �D n W. Springfield, MA (413) 781-2897 Quincy, MA (617) 479-2619 Mattapoisett, MA (508) 758-6633 Rhode Island (888)881-4598 Building Co Tdissioner or Inspector uildings Town oNorth Andover 160 sgood Street rth Andover, MA 01845 Attention: Records COMPANY: POLICY NUMBER: CLAIM NUMBER: INSURED: LOSS LOCATION: DATE OF LOSS: DESCRIPTION: OUR FILE NUMBER: Gentlemen: 8 Pittsfield, MA (888) 881-4598 Worcester, MA (888) 881-4598 Cape Cod & Islands (888) 881-4598 Hartford, CT (888) 881-4598 and of Health or oar of Selectmen Town of North Andover 1600 Osgood Street North Andover, MA 01845 Attention: Records Narragansett Bay Insurance Company 10489647 OIMA10489647 Osiris Rodriguez 255 Massachusetts Avenue, North Andover, MA 01/25/2015 Wt, of Ice & Snow B15-39906 Claim has been made involving loss, damage, or destruction of the above captioned property which may either exceed $1,000, or cause Massachusetts General Law, 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 this writer and include a reference to the captioned insured, location, policy number, company claim number, date of loss, and claim or file number. Sincerely, Jeff Mangarpan Claims Adjuster P — 603-742-9747 -office F — 617-479-1740 jeffm@georgebutleradjusters.com On this date, I caused copies of this notice to be sent to the persons named above at the address indicated above, by first class mail. Secretary November 16, 2015 209 Park Avenue, West Springfield, MA 01089 .r, Date .... 1...4. 6 ........................ e TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......................................................................................................................... has permission to perform ,..,.,..�-e� wiring in the building of.... h.f fI + "?tetI......................................................... at .......Q � .....".......� .�%.........4K ................ �'►. ,North Andover, Mass. Fee...4.a�........ Lic. No. `l`.�.......... 0� ...............1..'1;�............. C CTRICAL INSPECTOR Check a C/ ` Commonwea& of // 66a4weffj Oficial U Apartment o/..tUse Only c� c7ire service Permit No. 1 b "tn,q BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1107] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Codec ffMR 12.00 LEASE PRINT IN INK OR TYP A L ORMATION) Date: 2yI�.J� City or Town of: To the Inspector of Wiles: By this application the undersigned gives no-ticp of his or her ' t do to dorm the electrical work described below. L c on (Street & Number) 0 r or Tenant^ A r lkIJl* Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes—No ❑ (Check Appropriate Boz) Purpose of Building n �,Qf i�(1(1 �,q J- (C }(n -(a, Utility Authorization No. Existing Service!;Q Amps fail / 84() 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: Cmmnlvtinn nfthv Allnwina tnhlb mmy ho wnivoil by tho Tnana,f— of Al;— 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 n- rnd. El in- ❑ o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Vetection an 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 o. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑unicipal El Other Connection No. of Dryers Heating AppliancesKW Security Systems: No. of Devices or Equivalent No. of Water KW Heaters o. o No. of Si s Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Te ecommunications'ring• No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. F,stimated Value f ectric Work: �_ (When required by municipal policy.) Work to Start: ) Inspections to be requested in accordance with NEC Rule 10, and upon completion. INSURANCE C GE: 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 cov a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is nd complete. FIRM NAME: vwnt LIC. NO.; Licensee: Z am J\0( Signatur LIC. NO.: 141 A - (If applicabl , enter " empt" in the licede number line) Bus. Tel. No.: lkl- 105-:39L-46 Address:k CA� �'I Alt. TeL *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 ignature below, I hereby waive this requirement. ?I,am the (check one ❑ owner ❑ owner's a ent. Sinae Owner/Agent/ 4Zi Telephone No. �L `- 1 "� E I PEAWT FEE. $ The Commonwealth of Massachusetts Department of IndustrialAccidents (r Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name (Business/Organization/Individual): Vivint Solar Developer, LLC Address: 3301 North Thanksgiving Way, Suite 500 itv/Statel'Zi1J: Lehi, UT 84043 Phone 9: 801-377-9111 Are you an employer? Check the appropriate box: I am a employer with t 0 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors :. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. F-1We are a corporation and its ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. EJ Plumbing repairs or additions 12.❑ Roof repairs 1 AN Other Solar Installation *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-contractorF= state whether or not those entities have e 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: Zurich American Insurance Company Policy # or Self -ins. Lic. #: WC 509601300 Expiration Date: 11/1/2015 t Job Site Address: y City/State/Zip: , Attach a copy of the workers compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is gage and correct Phone #: 801-2296459 Official use only. Ido 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/'Towne Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: VIVINT SOUR DEVELOPER LLC PHILIP F ZA14P ITELLA JR (EL) 4931 K 300 K PROVO UT 84604 RDOUNKMNEACTU O 6L8 RiCI'M�m C i 1SSUE5 IRE FOLLOWINGE CINSE AS: MWSMET RAST -16L E CTR f C I AN Vt fMt SOLAR DEVELOPER LLC M1L1P ErAMVELLA JR 4931 N. 380 M !O ut 84604 t T41 .A 0713.L1.'Tt£t-.r :101!S�g � u�aa�ri■'u�iraa� 2Z5 Massachusetts Ave, North Andover MA 01845 or N O 71 �� � ''ww T d N V1 y cn z ry O Q 'G^ 'w/' ON -1 x (D r zQ N `J VJ N _-0 0 m mCl)N Dx N �nro 'KK �_ M5O0 N 00C m =Zm Oma vx� r-mx mooD I I I I I I I I I I • I 1 I I I CSr z 0 < ��A OO �> rxmoo �� C< C m p n z z N n Z m n< C/) 0 ZC) O() Zm. D C OOMO z0 I- Cn �Z-1-0 $o oar m s Cn0 xs XD� z �z X, S' Oxx _� m 0Dv n O m 0 II �. D n O z 0 O V) m z 845 �m >m INSTALLERNUMBER::187.404.4129 a�M �+s� Rodgripuez Residence PV 1.0 m SITE m ' MA LICENSE: MAHIC 170848����C V Li L I UB solar 5 MassachuNorth Andover, setts Ave PLAN DRAWN BY: JW AR 4172513 Last Modified: 3/24/2015 UTILITY ACCOUNT NUMBER: 78535-07022 ooh 000 ;0 N :D r 0 N OD C Cn On On r C r7 N N � C7 On C n rc M ;1 O 0m m m Z z y Cp o D < om fO m w Cf) N m II o X O O n � o Cn z Cn z r m Cm m ROOF D= m m INSTALLER:VIVINTSOLAR o�''(�j'y� Rodgriguez Residence INSTALLER NUMBER: 1.877.404.4129 �f PV 2.0 m m m �,.� u llrr Q 6a L! J U U U'r] sola 5 Massachusetts Ave MA LICENSE: MAHIC 170848 PLAN North Andover, 01845 DRAWN BY: JW AR 4172513 Last Modified: 3/24/2015 UTILITY ACCOUNT NUMBER: 78535-07022 BE o� T�� >O< 00 oZ 0o mo O D r r m r O = (n O0� Lj -00 opo ��p O DD 0 c ;0 Zm ZOZ c� m 71 -j D z O K0m O00 nr n pg0 90 D �D m� -0A � m E � D D 0 O m c)-� K0m 0 o D0 o� < m C Z O opo �D 0-0 ° D --iz m--1 Z co O =+ m n X r- z m Z m X ^ I`J > a m Z. O r, m(q D O z D M r m 0_ ;u Mm T OrK fnD r mK z 50 ft 9 " 0 (1) ;0 t7 -o ^Z UJ N FF 05 N ;p z 0 ;zmm y L7 D O r O v n n O OC C7rcnr ��DM 0 Z n -D-I 0r -0O(Oi» m D 17 n Amo < m n D _ n K ZK a m >o� o 0 r � 00 m x. m K Cn N W -a U mz -I Z c i Km " MOUNT. y = m m INSTALLER: VIVINT SOLAR n GRI Rodgri9uez Residence Massachusetts Ave INSTALLER NUMBER: 1.877.404.4129 MA LICENSE: MAHIC 170848 PV 3.0 m p DETAILS �1 - LJ� t North Andover, MA 01845 DRAWN BY: JW AR 4172513 Last Modified: 3/24/2015 UTILITY ACCOUNT NUMBER: 78535-07022 0 < < N nn S ' o n � 3; 3 O C O C mz = Sal � • • Aw zm cmi39 ° N Oce Gm Ao<3 N • • • • N p� �n >m�<n O� z0 �O O- mo �m • • 0 • • O p nm D� 3 0 (npm C C D r -o mm x �� C S I I m i t m m Z O N m N r N o m O � O - g v a_ z Ql O 070 m z OAO 0 I m I m it r C3 5 I mIll X I I o I I I I I I I O�/tea m i p1�%j5^^'04 mg<v oo' >v ov v� z N // `\`O z n=n� ZN -i m" <nT < C O zOD o D m AO N Z N mx mn m m m O fn oanD mm G7�m Nim v'x� T y yam<d < D c d U7 cu a) mm 030 ZmD zm< a + �m 3®A3 C° pm � � p-4> pip Z w 3moe.a co m o p^ NIN On A np n 1 0 2 m m /1 O v a N v A-1- O 2Cr X m Z XmC A tC N O D X z an d (n Oz y°c mAD ZID zx� m m / I Z m y m fn %-i< ml mm� Dmp� DON A mmmo� jm cD m N <mrA mC Viz- CN cD n po�$p o 3 O ,n N4Cm mA^ z� mm m� m D 11D GAUNiMp D< D m z�0 D� Zp m0 mw 1 y I /J r- mD z3 ° m z<n 1n i7o zA -4m w mAA;0 Cn c o n (n o Amno 0z .0 �o Nimn c e m ? 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Project Information Project Name: Betsie Rodgriguez Project Address: 255 Massachusetts Ave, North Andover MA A. System Description: The array consists of a 5 kW DC roof -mounted Photovoltaic power system operating in parallel with the utility grid. There are (20) 250 - watt modules and (20) 215 -watt micro -inverters, mounted on the back of each PV module. The array includes (2) PV circuit(s). The array is mounted to the roof using the engineered racking solution from Ecolibrium Solar. B. Site Design Temperature: (From Lawrence MUNI weather station) Average low temperature: -24.3 °C (-11.74 °F) Average high temperature: 37.6 °C (99.68 °F) C. Minimum Design Loads: Ground Snow Load: 50 psf (State Board BR&S) Design Wind Speed: 100 mph (State Board BR&S) 2. Structural Review of PV Array Mounting System: . A. System Description: 1. Roof type: EcoX Comp. Shingle 2 -Method and type of weatherproofing roof penetrations: Flashing B. Mounting System Information: 1. Mounting system is an engineered product designed to mount PV modules 2. For manufactured mounting systems, following information applies: a. Mounting System Manufacturer: b. Product Name: c. Total Weight of PV Modules, Microlnverters, and Racking: d. Total number of attachment points: e. Weight per attachment point: E Maximum spacing between attachment points: g. Total surface area of PV array: h. Array pounds per square foot: i. Distributed weight of PV array on roof sections: Ecolibrium Solar Ecorail 928 lbs 39 23.79 lbs * See attached engineering talcs 352.2 square feet 2.63 lbs/square foot -Roof section 1: (20) modules, (39) attachments 22.05 pounds/attachment 3. Electrical Components: A. Module (UL 1703 Listed) Qty Trina TSM 250-PA05.18 20 modules Module Specs Pmax - nominal maximum power at STC - 250 watts Vmp - rated voltage at maximum power - 30.3 volts Voc - rated open -circuit voltage - 37.6 volts Imp - rated current at maximum power - 8.27 amps Isc - rate short circuit current - 8.85 amps B. Inverter (UL 1741 listed) Qty Enphase M215-60-2LL-S22 20 inverters Inverter Specs 1. Input Data (DC in) Recommended input power (DC) - 260 watts Max. input DC Voltage - 45 volts Peak power tracking voltage - 22V - 36V Min./Max. start voltage - 22V/45V Max. DC short circuit current - 15 amps Max. input current - 10.5 amps 2. Output Data (AC Out) Max. output power - 215 watts Nominal output current - 0.9 amps Nominal voltage - 240 volts Max. units per PV circuit - 17 micro -inverters Max. OCPD rating - 20 amp circuit breaker C. System Configuration Number of PV circuits 2 PV circuit 1 12 modules/inverters PV circuit 2 8 modules/inverters (15) amp breaker (15) amp breaker 2011 NEC Article 705.60(B) Vi lrr]t i D. Electrical Calculations 1. PV Circuit current PV circuit nominal current 10.8 amps Continuous current adjustment factor 125% 2011 NEC Article 705.60(B) PV circuit continuous current rating 13.5 amps 2. Overcurrent protection device rating PV circuit continuous current rating 13.5 amps Next standard size fuse/breaker to protect conductors 15 amp breaker Use 15 amp AC rated fuse or breaker 3. Conductor conditions of use adjustment (conductor ampacity derate) a. Temperature adder Average high temperature 37.6 °C (99.68 °F) Conduit is installed 1" above the roof surface Add 22 °C to ambient Adjusted maximum ambient temperature 59.6 °C (139.28°F) b. PV Circuit current adjustment for new ambient temperature Derate factor for 59.6 °C (139.28°1,� 71% Adjusted PV circuit continuous current 19 amps c. PV Circuit current adjustment for conduit fill Number of current -carrying conductors 6 conductors Conduit fill derate factor 80% Final Adjusted PV circuit continuous current 23.7 amps Total derated ampacity for PV circuit 23.7 amps Conductors (tag2 on 1 -line) must be rated for a minimum of 23.7 amps TI-IWN-2 (90 °C) #12AWG conductor is rated for 30 amps (Use #12AWG or larger) 4. Voltage drop (keep below 3% total) 2 .Darts: 1. Voltage drop across longest PV circuit micro -inverters (from modules to j -box) 2. Voltage drop across AC conductors (from j -box to point of interconnection) 1. Mirco-inverter voltage drop: The largest number of micro -inverters in a row in the entire array is 12 inCircuit 1. According to manufacturer's specifications this equals a voltage drop of 0.41 %. 2. AC conductor voltage drop: = I x R x D (= 240 x 100 to convert to percent) _ (Nominal current of largest circuit) x (Resistance of #12AWG copper) x (Total wire run) _ (Circuit 1 nominal current is 10.8 amps) x (0.0020152) x (80D - (240 volts) x (100) 2011 NEC Article 705.60(B) 2011 NEC Article 705.60(B) 2011 NEC Article 705.60(B) 2011 NEC Article 705.60(B) 0.41% 0.72% Total system voltage drop: 1.13% vt�IriT • EcolibriumSolar Customer Info Name: 4172513 Email: Phone: Project Info Identifier: 27488 Street Address Line 1: 255 Massachusetts Ave Street Address Line 2: City: North Andover State: MA Zip: 01845 Country: United States System Info Module Manufacturer: Trina Solar Module Model: TSM -250 PA05.18 Module Quantity: 20 Array Size (DC watts): 5000.0 Mounting System Manufacturer: Ecolibrium Solar Mounting System Product: EcoX Inverter Manufacturer: Enphase Energy Inverter Model: M215 'Project Design Variables Module Weight: 41.0 lbs Module Length: 64.95 in Module Width: 39.05 in Basic Wind Speed: 100.0 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 IV Lag Bolt Design Load - Lateral: 288 IV EcoX Design Load - Downward: 722 IV E�coX Design Load - Upward: 765 Ibf EcoX Design Load - Downslope: 297 IV EcoX Design Load - Lateral: 233 IV Module Design Moment — Upward: 3655 in -Ib Module Design Moment — Downward: 3655 in -Ib Effective Wind Area: 20 ft2 Min Nominal Framing Depth: 2.5 in Min Top Chord Specific Gravity: 0.42 Plane Calculations (ASCE 7-05): 1 Roof Shape: Gable Roof Type: Composition Shingle Average Roof Height: 15.0 ft Least Horizontal Dimension: 15.0 ft Roof Slope: 25.0 deg Truss Spacing: 16.0 in Snow Load Calculations Edge and Corner Dimension: 3.0 ft Stagger Attachments: No Include Snow Guards: No EcolibriumSolar Description Interior Edge Corner Unit Flat Roof Snow Load 42.0 42.0 42.0 psf Slope Factor 0.82 0.82 0.82 psf Roof Snow Load 34.4 34.4 34.4 psf Wind Pressure Calculations Description Interior Edge Corner Unit Net Design Wind Pressure Uplift -16.0 -26.4 -39.6 psf Net Design Wind Pressure Downforce 9.4 9.4 9.4 psf Adjustment Factor for Height and Exposure Category 1.0 1.0 1.0 psf Design Wind Pressure Uplift -16.0 -26.4 -39.6 psf Design Wind Pressure Downforce 10.0 10.0 10.0 psf .ASD Load Combinations Description Interior Edge Corner Unit Dead Load 2.3 2.3 2.3 psf Snow Load 34.4 34.4 34.4 psf Downslope: Load Combination 3 14.2 14.2 14.2 psf Down: Load Combination 3 30.4 30.4 30.4 psf Down: Load Combination 5 12.1 12.1 12.1 psf Down: Load Combination 6a 30.8 30.8 30.8 psf Up: Load Combination 7 -14.7 -25.1 -38.3 psf Down Max 30.8 30.8 30.8 psf .pacing Results (Landscape) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 59.1 59.1 53.0 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 19.7 19.7 17.7 in Spacing Results (Portrait) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 45.0 45.0 41.1 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 13.7 in EcolibriumSolar Layout Skirt o Coupling O Clamp 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 Weights In Conformance with Solar ABC's Expedited Permit Process Module Quantity: 20 Weight of Modules: 820 lbs Weight of Mounting System: 78 lbs Total Plane Weight: 898 lbs Total Plane Array Area: 352 ft2 Distributed Weight: 2.55 psf Number of Attachments: 39 Weight per Attachment Point: 23 lbs EcolibriumSolar Bill Of Materials Part Name Quantity ECO -001_101 EcoX Clamp Assembly 39 ECO -001_102 EcoX Coupling Assembly 23 ECO -001_105B EcoX Landscape Skirt Kit 0 ECO -001_105A EcoX Portrait Skirt Kit 4 ECO -001_103 EcoX Composition Attachment Kit 39 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 20 ECO -001_338 EcoX Connector Bracket 20 ECO_001-359 EcoX Lower Support - Low Slope 0 Dermit NO: 0 /�- I \-Oate Issued: t%ORT BUILDING PERMIT 0 0 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building KOne family 0 Addition 11 Two or more family 11 Industrial 0 Alteration No. of units: El Commercial ,KRepair, replacement 0 Assessory Bldg 0 Others: 11 Demolition 0 Other W, N 1 117 P %,imp"rSP!, bd 'R tl _W i'm A M, "... �A_ no OWNER: Name Address: 3 6 dlAoa valm. Identification Pleas -e Type or Print Clearly) Oen U C Phone: 61 KL ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. otal Project Cost: $ 00.(0 FEE: $ "--z heck No.: Receipt No.: NOTE: Persons coAtr"acYng with unr - iste d contractors do not have acceFs tothearantyftind ature of Agent/ e.., Signatureof Sion wn / Z,/!.`'� Date.. ?/ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that has permission to perform Y....�� , I;A,.. �%, I ...................... wit.kng in the building of....... . ........ .................... at .Z� ... 14q--�-S 11C .. .... �rogrtffih Andover, Mass. ............................................................ .. ........ 1515DO R4119 Fee ................. ...... Lic. No . ................. ............... _�2 .............................. ...... ...... O� ............ EL C-MCAL INSPECTOR Check 11746 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 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 (NEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: -7- Z- q -13 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of llis or her inteigion to perform the electrical work described below. Location (Street & Number) S / Owner or Tenant K - r- & -� %it , Telephone No. Owner's Address -- -^-�— Is this permit in conjunction with a buildinpermit? Yes No F1 (Check Appropriate Box) Purpose of Building �� •� e - "� I, � Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ 14,A--,, Undgrd ❑ No. of Meters Undgrd ❑ No. of Meters ,.._-0 L. Completion of the followinz table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. grnd. No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices NCO. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat PumpNumber Totals: .. 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 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: Atiach additional detail if desired, or as required by the Inspector of Wlres. Estimated Value of Electrical Work: �' ©� (When required by municipal policy.) Work to Start: 7- 2-T—( 3 Inspections to be requested in accordance with NEC 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 cover5p is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) I certify, under thepag*wndpenaltio erjury, that the information on this application is true and complete. FIRM NAME:. �- ..�..� z� L� . LIC. NO.: 3 `t Licensee: ,-,�� �� Signature LIC. NO.: (If applicable, enter "exemp " in the license �}}umber line.) Bus. Tel. No.•y ®3 -�c-6T &Z Address: 2 v d L4 --� << S- WAlt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Departrilent of Public Safety "S" License: Lie. 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. 1� ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § K. Permits shall.be limited as to the time 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 IN Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass R Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: r Pass F?1 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: r. Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: f4 Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectorsmments: �� �' � ,� -�� -s x440 -f Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Uf www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ^ Please Print Legibl, Name (Business/Organization./Individual):- Address: 0 City/State/Zip:_ 6 3 �_ C_C�_ Phone #: / � Q � — S"l �—G- Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I S*11Yyees (full and/or part-time).* have hired the sub -contractors 2.01 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 repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. A Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit a new affidavit indicating such. tCoptractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. Job Site Address: Expiration Date: 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 DTA for insurang,�,,.ceversge verification. I do hereby cert 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 # -7-Z,7 `3 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 #: ra 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 n year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Dopaftent of Industrial Accidents Office of Iavestigatitons 600 Washington Stxeet Boston., MA 02111 Tel. # 617-727-4900 ext 406 or 1-$77,7MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.Mass.govfdia 50,