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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 itl W �` a3'� w °ia.fz� •� :': Q ul ejnleuBig � 1 • �. N N1 UJ �t . 4. Z J., r g O� Q ; w- J U- ZAu �w a ; U 2, w E M ILU :C: d ra LU w s W z uit� itl W �` a3'� w °ia.fz� •� :': Q ul � 1 • �. N N1 Q ; w- J U- ZAu LL: a ; U 2, w E M co QtO1 Q :C: d ra w s W z uit� lit a c a itl W �` a3'� w °ia.fz� •� :': Q ul cC U = L l� Q F � � a is i° � •°� I a c Cc, . L TR,C ? 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Wim. 0 zo�z Zsa° _. OO mm2D o O ---i K Z co i 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 r r 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 / s-! 4, a v✓ICL�rl rI �w `���?� �11, -- 1,; 1'l' law, �, CC41 -j4 d6 —,, fz<Z /o ���.�,` J�4- - Sly S — I/, 14 ---?. 6i 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 In O F=4 0 O� P? F w x w O A x m v ua w° E CL cn a o w z z A L w° p v L U u G w a w z z z O w m C w o z a U u WF p cG a~i cn C w a U wj z ¢ p o: C w d a Q w 3 w z cn o cn 0 U) W N y .co co C O Q 0 _Q CL O O Q V .Q N! C O U.O _R Q CO2 i O Q O Q. 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