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Home My WebLink AboutMiscellaneous - 28 DUNCAN DRIVE 4/30/2018 (2)C �' ".1 Date.... ............................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that .... .................................. . .................... ................... . .......... has permission to perform ..... -. ............... :� ............ wiring in the building of ... ............................................ at ...... �? ........ :7= :.n ...... .................... North Andover, Mass. Fee -10 .............. Lic. No . ...... . .......... ........... Check # iICAL &SP�� R-- Commonwealth of Massachusetts e -n Us �9 0 Offici� . FPermi,t No. �7 X5-9 Department of Fire Services Penn"No- - cc�pr y c e Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC) 527 ��R 12.00 (PLEA SE PRINT 17V NK OR TYPE ALL INFORMA TJOA9 Date: /0/ /61 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) 9-4 0"WA " n A () Owner or Tenant yez I., L SkA1n-,7 Telephone No. Owner's Address 9 -CV t9f,.Al,^ 1),JJ-f Is this Permit in conjunction with a building permit? Yes ' No 0 (Check Appropriate Box) Purpose of Building KJidlf, ke me h C- Utility Authorization No. Existing Service /,00- Amps JZ0 / 7,40 Volts New Service Amps Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead 0 Undgrd No. of Meters OverheadEl Undgrd No. of Meters (764- f-\ Estimated Value of Elptnical Work: ��00, 00 --- 1/ austrea, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: lolz6k( 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'9' BOND [] OTHER El (Specify:) I certify, under thepains andpenalties ofperjury, that the information on this application is true and complete - FIRM NAME: teh-t C, I 11�1a" pr oe— LIC. NO.: 2c, .6"13 f Licensee: I 4,,7 rt� Signature (Iftipplicable enter Ilexe t the lijense n b r line�,,, LIC. NO.: Address: 'i 0 !2 77 b-je-a, 4V B u s. T el. N o Ij *Per M.G-L c. 147, s. 57-61, security work requires Department of Public Safety "S" Lice Alt. Tel. No.: Lic. No. th I ty insurance coverage normally OWNER'S INSURANCE WAIVER: I am aware that the Licensee does no have nse: t e liabi i required by law. By my signature below, I hereby waive this requirement I am the (check one) Owner/Agent owner D owner's agent Signature Telephone No. PERMIT FEE:$ t\ Tke Common wealik of Massirchuse& Department of Industrial Accidents Office of Investigations. i 41. ). Vill 600 Washington Street Boston, M4 02111 U WXW.17zMS.gov1dia Workers' COMPeRsation Insitrance Affidavit: Buflders/Contractors/Electricians/Plumbers Applicant Information Plea ibi A em Nanie Address: 90� c/ I (,'v c,^ citystate/zip: M-) 69 /1 t#hone I Are you an employer? Check the appropriate box: I - 1116113 a employer with 4.13 1 am a general contractor and I .,M)Ployees (full and/or part-time).* have hired the sub-contructors 1 am a.sole proprietor or partner- listed on the attached sheet ship and have no employees These sub -contractors have working for me.n any capacity, workers' comp. insurance. [No workers' comp. insuranc'e 5. We are a corporation and its required.] 3. F1 I am a homeowner doing officers have exercised their MOL all work right of exemption per myself. [Noworkirs, comp. c. I.5Z § I (4),'and we have no insurance required.] t -employees. [No workers' comp. insurance require&] *Any applicant that checks bo)t* I must also fill out the section below showin Type of project (required): 6. New construction 7. Remodeling 8. Demolition 9. Building addition 10. E3 Electrical repairs or additions I 111 Plumbing repairs or additions 12.E] Roof repairs 11[1 Other 5. MM on poi icy inTormation, T Homeownm who submit this affidavit indicating they are doing all wotk and then him outside contmetors must Submit a new affidavit indicating guciL lConftctors that check this box must attached an additiozzal Shea showing. the name ofthe sub-conbactDrs and their worken;, cbm 'P. policy infomlaqon. am aH employer &V isprw?vidjng:w0rkerS1 compensation iJzSUFRNCef0rnV eftlFloyeeM Below is the PO&7 andjoh site infomwdon. Insurance Company Name: PORCY # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/state/zip: Attach a copy . of the workers' compensation policy deelamflon page (showing the policy number and expiration date� Failure to secure coverage as required under Section 25A of MGL c. I S2 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 cerdfj der and aldes Y th a' eriury that the inffir""OAPMMedabo istrueandcorreeL pen 0fP Date: ly. Do= 0 wr�� City or Town: PermiMicense Issuing Authority (circle one): I. Board of Health 2. Building Department 3. Cityfrown 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 mplayee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An enVloyer is defined as "an individual,, partnership, assodiation, corporation or other legal entity, or any two or more of the'foregoing engaged in a joint enterprise, and including the I epl representatives of a deceased employer, or the receiver or timstee, -of an individual, partnership, association or other legal entity, employing employees. 'However the own6r.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 wdd� on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MOL chapteT 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to opemte a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence,of compliance with the insurance i coverage requimd." Additionally, MOL 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 evildence, of compliance with the insurance requirements of this chapter have been presented to the contwting 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.. Aiso'be sure to sign and date the afridavit. The affidavit should be returned to the city. or town that the application for the pem'it or license is being req uest4 notthe Department of Industrial Accidents. Should you have any quest.ions 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-insuran6e'license number on the'appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department his 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 inclicating,current policy *information (if necessary) and under,."Job Site Address" the applicant shouldwrite "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. Whem a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license of permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigptions would like to thank you in advance for your cool*ration 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 Offlee of Investigations 600 Washington Str�et Boston, MA 02111 Tel. # 617-727-4900 6xt 406 or 1-8-77-MASSAFE Fax # 617-727-7744 Revised 5-26-05 www.mass.gov/dia Date./. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING S CHUS This certifies that ... ...................... has permission to perform .... -4't. ................. plumbing in the buildings of . A . . ................. at. . . ................ North Andover, Mass. Feef//. Lic. No.!! ....... ... . L ;�� ................ PLUMBING INSPECTOR Check # / ) 1, .7 — C 0 0 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMIRIN (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Location &AtN W/ owners Name Av Permit # Amount Type of Occuoancv New 0 Renovation 1-1 Replacement FIXTURES Plans Subinitted Yes No (Print or type) Check onel� Certificate Installing Company Name Address Partner. Business Telephone Firm/Co. Name of Licensed Plumb er: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature owner M Agent 11 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 p�eo Wed Ccde' Pen -nit Issued for this application will be in compliance with all pertinent provisions of the Mas,%achtsetts tel u Code and Chapter 142 of the General Laws. /d y: 1APPROVED (OFFICE USE ONLY Type of Plumbing License / () 2 f- 6 r7cense 7771577 Master 0/jounicyman n 44 77ze of Massachusetts Depontment of Public Sofdy Permit XG. —d-61 occups"CY4 lat chethe _,0 lug BOARD OF FIRE PREVENTION AEGUIAT)ONS SV CMR 12:00 3/90 (leave blanki APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK AS wwk to be pufamed In accordance with the Maesachwitas Elwrkal Cod% $27 CMR 12:00 (PIXASE PRX.HT XH 3NK -OIL TUR ALL MMF%=0N) Date MY ov Towh of hlo, Ahk--\,2, Y-eA-- To the Inspector of virest 1he undersiped applies for 4 Permit to Perform the electirical work described below. Location (street & Pumber) - 2_1 --tL A5(\--7 Ovnerorlewwt ?,ALA Owner's Address 'Is this Permit IS conjunction vLth a building permits Yes[] (Check Appropriate Box) Purpose of Utility Authoritation NO. Existing Service Amps volts Overhead Vndjr4 No. of Meters New Service Amps Volts Overhead Undgrd No. of Meters N=ber of Feeders and Ampacity Tocation and Nature of Proposed Electrical Work - N k. , - 1% _L - _%, � -->- - t - , No. of Lighti"tlets No. of Not Tubs Total No. of Transformers KYA No. of Lighting Fixtures Swimming Pool Abov 0 in-. 0 grnd Generators KVA No. of Receoi;eze outlets I _Srnd! No. of Oil Burners No. of Emerjency Lighting Battert 11ni 0 �0. of Switchlbutlets No. of Cas Burnqx; FIRS ALUM No* of Zones 16. of Detection and Initiating Any1ces No. of Soundths Devices No. of Sell Contained Detection/Sounding Devices Local 0 KMLCLP&l connectionoOtber No. of Ranges Total No. of Air Cond. tons No. of Disposals He I Total Total go. of Pu a Tons KW No. of ftshw�4h�rs Space/Area Hilating XW No. of Dryers i Beating Devices W No. of XW Water He+ters No. of I Sixns Ballasts Low Voltage Wirinit No. Ilydro N&ssage Tubs I No. of Motors Total HP INSUMCE CDVER=t Pursuant to the requirements of Massacilusetts Ceeiral Wis I have a current LIsbL1Lq Insurance Policy Including Completed Operations Coverage or Its substantial equivalent. - YES W NO IJ I have sut;mitted valid proof of same to this office. YES[] No [] If you have checked YES, please Indicais the type of coverage by checking the appropriate. box, INR"C2 0 OMM C] (Please Specify) Est , (Expirstlon a eT imated Value of Electrical Work $ Work to Start Inspection Date Requesteds . Rou Final Signed 4L.4er the penalties of perjurys FM LIC. NO. A4.4ress-1 175-7. MA But. Tel. No. W3- I- I k 241. No. OM'S 'HSt"MC19 WAXViRl 2 be aware* that' the FLIcenses does not h!n,the bsutshce coverage or its. sub, stsatist 4quivAllut 90 feqUifed by Massachusetts Ceneral Laws, ana that my signature on this oeimLt OPPILCOtioli waives this requirement. owner. Agent (Please check one) , Telephone No. (Signature of er of W-g—ew F N2 Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING 8 Ui Thiscertifies that ............................................................................................. has permission to perform ... ...... ................................................ ....... wiring in the building of ........... ........ ..... . ....... ............................... at .................... ...... .............................. North Andover, Masis� Fee4.' ...... ........... Lic. No� 4�/J� ......................................... I .................... ELEcrRicAL INSPEc-rOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer