HomeMy WebLinkAboutMiscellaneous - 28 WOOD AVENUE 4/30/2018j
Date ... ..............
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Thiscertifies that ............................................................................ ..... .. ....................
has permission to perform. . ............ ......
7*'***",r'****'**'
wiring in the building of
at ...... ................. Alorth Andover, Mass.
Fee
I . ......... Lic. No? ..... ..... ..
L-*'
LLE*(' �ECTO!R
Che6k #
11514 a P00'e W, /- &Iva -1,3
/A
k
`A Commonwealth of Massachusetts Official Use Only
Permit No.
�1
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07j (leaveblank
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 ININK OR TYPE ALL INFORMATION) Date: /� 2
aCity or Town of: NORTH ANDOVER To thdfnapktor of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number)JJQ
Owner or Tenant Telephone No.
1 Owner's Address 1
Is this permit in conjunction ith a uildiper it? Yes No ❑ (Check Appropriate Box)
Purpose of Building ` 7�,^�, Utility Authorization No.
- Existing Service ��_ Amps Volts Overhead Undgrd ❑ No. of Meters .*0
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of feeders and Ampacity /
Location and Nature of Proposed Electrical Work:1lzJ k� l `ch4 ir/ Z"
Comnletinn nfthe following table may be waived by the inspector of Wires.
No. of Recessed Luminaires
No. of Cell. -Sus p (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimmin Pool Above ❑ In- ❑
g rod. rod.
o. o meig ttng
BatteryUnits
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection ondInitiating Devices
No. of Ranges
Tot
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Dis osers
P
Heat Pump
Totals:
Number
Tons
............. **
KW .....
.................
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
p g
Local ❑ Municipal El Other
Connection
A. of Dryers
Y
Heating Appliances KW
Securiiy Systems:Y
No. of Devices or Equivalent
Np. of Water KW
Heaters
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:
Attach additional detail if desired, or as required by thelnspecror a vv tree.
Estimated Value of Ele trical Work: (When required by municipal policy.)
Work to Start: tG Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE O RAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, under the ins a d penalties o perjury, that the information his application is true and complete.
FIRM NAME:. s! 07� iv r FC iC - �G LIC. NO.:
Licensee: Signatu LIC. NO.: G 7
(If applicable, enter "exempt" in the license number line.) Bus. Tel. No.-.62ia?
Address: 3j;/,15T S)-r�W46a- 'A - !tel Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, ge6drity work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent PERMIT FEE: $
Signature Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the Y�
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, § 3L.
Permits shall be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
❑ Rule 8 — Permit/Date Closed: * * * Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass
Failed ❑'
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
,
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass M
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
7
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) ❑
Inspec rs Comm nts:
Inspectors Signature:
Date:
FINAL INS ION:
Pass
Failed IN
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date: ',?o
DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
Uq.F. www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/organization/Individual): c),,o/, )l%t/�j _L�/_c
Address:��'
City/State/Zip: Phone 4:4?a)
Lre yn employer? Check the appropriate box:
❑
Type of project (required):
I am a employer with _ 7
4. I am a general contractor and I
6. ❑ NeVL construction
employees (full and/or part-time).*
❑ I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet. #
7 Remodeling
ship and have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.
9. ❑ Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
10.❑Electrical repairs or additions
requi med.]
❑ I am a homeowner doing all work
of cers have exercised their
right of exemption per MGL
11.❑ Plumbing repairs or additions
mysf. [No workers' comp.
c. 152, §1(4), and we have no
12.❑ Roof repairs
insurance required.) t
employees. [No workers'
13.❑ Other
comp. insurance required.]
iy applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
)meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ntractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
Fn an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site
grmatiom
arance Company Name:.
icy # or Self -iris. Lid. #: Expiration Date:
Site Address:City/State/Zip: �
ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
t 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
tp to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
estigations of the DIA for insurance coverage verification.
P hereby,-eertify u#rd# tgph ins qdd penO ies of perjury drat the information provided above is true and correct.
3_/Y
)fficial use only. Do not write in this area, to be completed by city or town official.
:ity or Town: Permit/License 0
ssuing Authority (circle one):
Board of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector 5. Plumbing Inspector
Other
'.nntarf PPrenn• Phnnn V!
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 nbt 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 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.
rhe Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
?lease do not hesitate to give us a call.
he Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MM 021.11
Tel. # 617-727-4900 ext 406 or 1877-MASSAFE
*PA -v f! 617777_7749
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L6cation 2,. ' _Z22,2 ,,
Wo. Date
"ORT"
TOWN OF NORTH ANDOVER
A
Certificate of Occupancy
Building/Frame Permit Fee
$ ----
�e ,•4,'
$
�'� SATN�SES�
Foundation Permit Fee
$ --------
Other KgF �ee`"�
$ � �>
Sewer Connection Fee
$ ---'— "-
Water Connection Fee
$
TOTAL
,,ggam�$
'Building- Inspector
12/09/93 09:27 52.V PAID
TO
6785
Div. Public Works
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Visit Our Showroom At
#5 Rte. 28
Windham, NH 03087
100 Yards, North of Rte. 111
Weds - Fri 12-5
Sat - 9-2
898-2259
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T Wil I
&. REPLACEMENT WINDOWS
Proposal - Agreement
Famous Brand Names
• Certainteed
• Mastic
• Andersen
• Harvey
• Therma-Tru
PROPOSAL� SUBMITTED TO(—
PHONE / �i DATE l� �G !j?
STREET
JOB NAME
CITY, STATE & ZIP CIODE
JOB LOCATION
DATE Of VILAN5
We hereby propose to furnish all materials and labor necessary for the completion of the following products in accordance with the
specifications and drawings.
/VI rtiCL ✓A�*L (/( it /
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Total contract price is:.� G .fir r fl�'u S� C'. d �- 1-e�r dollars ($ �calli V� )
PAYMENT TO BE MADE AS FOLLOWS.
All material Is guaranteed to be asspecHied. All work tobecompleted inaworkmanlike Authorized
manner according to specifications per standard practi)es. Any alteration or deviation Signature
from above specifications Involving extra cost will be executed only upon written orders
and will become an extra charge over and above the estimate. All agreements NOTE: This proposal may be withdrawn by us if not accepted within
contingent upon strikes, accidents, or delays beyond our control. Owner to carry fire,
tornado and other necessary Insurance. days.
ACCEPTANCE OF PROPOSAL - The above prices, specifications and conditions are
satisfactory and are hereby accepted. You are authorized to do the work as specified. /
Payment will be made as outlined above.
Signature
CUSTOMER has the right to cancel this contract up to THREE (3) DAYS after date of
acceptance.
Date of Acceptance //% A' Signature
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