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Home My WebLink AboutMiscellaneous - 26 HARWOOD STREET 4/30/2018ON Date ....... ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING x This certifies that ............. ................................................................................ has permission to perform................................. z ... ................. wiring in the building of at ................... ...................... ............. ............. ,North Andover, Mass. .............. Lic. ...... Fe� N Check #-fl Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. �%� d Occupancy and Fee Checked C�r [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date: 11-2-2-01 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) 2 -4;(14R -w E)0 `J t5 7— Owner Owner or Tenant 114 -P --K S O L ra t3 4 4LI Telephone No. Owner's Address S AA4 kF Is this permit in conjunction with a building permit? Yes ❑ No ff (Check Appropriate Box) Purpose of Building S//lfGGC F/1"jG1/ /y0 VSG Utility Authorization No. S 510 3 It 0 Existing Service n/ 6 0 Amps 12-01 7� 07olts Overhead Undgrd ❑ No. of Meters New Service 200 Amps 120 / 2— tOVolts Overhead Undgrd ❑ No. of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: U A'' E 6 / S �7,ovG /0,04 CF -LOW To 0 6 w 2,60w - s -�� .UO . �_.•�. u-u««.tut ueia:i aesirea, or as required by the Inspector of Wires. Estimated Value of lectrical Work: (When required by municipal policy.) Work to Stark ! ZZ —o Ins ections 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 co rage 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 true and complete - FIRM NAME: {) FJty r� Licensee: LIC. NO.: Signature LIC. NO.: .�� q �% (If applicable� ""enter "exempt " in the license number line. Address: 7 /ire to / /,V�j J,f /4��1� Bus. Tel. No.: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ _ •_c k, r t j The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Nrashington Street Boston, MA 02111 It i www.ntzass.gov/dia . Workers' Compensation Insurance Affidavit. Builders/Contractors/Eiectricians/Plumbers Applicant Information Please Print Legibly Name (Business/oilmization/individual): Address: I rl"4t--,7 0-t City/State/Zip: U/IG111p/ fid// IM- ®P Phone #: Are you an employer? Check the appropriate box: 1. ❑ 1 am a employer with 4. ❑ 1 am a general contractor and I rriployees (full and/or part-time).* have hired the sub -contractors 2. J 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. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ 1 ant a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No-worke'rs' 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. D Remodeling S. D Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other -ter »w• w.w� �ux n t must arso nu out the section below showing their workers' dompensation 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 nate of the sub -contractors and their workers' comp. policy infomration. 1 amt an employer that is.provuling:workers, information. compensation Imurancefor my employees: Below is the policy and job site Insurance Company Name: Policy # or Self -ins. LIC. #: Expiration Date: � Sob Site Address: ),6yiQ � "Q.. O a A' OI City/State/Zip: - L � 0 V 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 u der the pains and penalties of perjury that the infnrmratiion provided above is true and correct Si Lure: 2- y� Date: Of, j`wkd 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): I. Board of Health 2. Building Department 3. City/Town Cierk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: ,r 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 enWlayer 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 numberlisted 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 permitllicense number which will be used as a reference number, in addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigaations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, 1v1A 02111. Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFB Fax # 617-727-770 Revised 5-26-05 Wwwanass,gov/dia Date. 4 � � .......... ,,ORTH TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION This certifies that ...T/- ? .% f 4.c ................... . has permission for gas installation .. f?: a.:7. !!�................. in the buildings of . . `.... !?C � ......................... at .1 6 .................. . North Andover, Mass. Fee.: Lic. No..:".1:-.3.... .......................... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO QASFITTING (Print or Type) / v < 141 1&4ef Mass. Date 64 19Permit # Building Location rvl ") r D ;a/rlIffla 5774- Owner's Name �)TAa Type of Occupancy iR 1�-5I 17CN T! P t G� New ❑ Renovation ❑ Replacement 21"' Plans Submitted: Yes❑ No ❑ Installing Company Name it e-jAeg T A . ` ANN MA Tr-) X20 Address 3 0-0A C H ih H ry i- K1. 111t= 7H U e t 01 rl 0lk�{y Business Telephone /o 1-14� Z - Name of Licensed Plumber or Gas Fitter Check one: ❑ Corporation ❑ Partnership 2-'Mrm/Co. Certificate INSURANCE COVERAGE: I have a current I' bilary insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked Yes, please indicate the type coverage by checking the appropriate box A liability insurance policy dQ Other type of Indemnity ❑ Bond ❑ QWNER-S INSURANCE .WAIVER: 1 am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent [3 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the pe i X!or this application ' be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 ofneLws. BY T of license: C� Plumber n ure of cen u _. or fitter Title tter er License Number X333 CitYRzyoma USE ONLY) Journeyman )0 0 NONE Installing Company Name it e-jAeg T A . ` ANN MA Tr-) X20 Address 3 0-0A C H ih H ry i- K1. 111t= 7H U e t 01 rl 0lk�{y Business Telephone /o 1-14� Z - Name of Licensed Plumber or Gas Fitter Check one: ❑ Corporation ❑ Partnership 2-'Mrm/Co. Certificate INSURANCE COVERAGE: I have a current I' bilary insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked Yes, please indicate the type coverage by checking the appropriate box A liability insurance policy dQ Other type of Indemnity ❑ Bond ❑ QWNER-S INSURANCE .WAIVER: 1 am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent [3 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the pe i X!or this application ' be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 ofneLws. BY T of license: C� Plumber n ure of cen u _. or fitter Title tter er License Number X333 CitYRzyoma USE ONLY) Journeyman )0 w W W V d