HomeMy WebLinkAboutMiscellaneous - 296 RALEIGH TAVERN LANE 4/30/2018 (2)N
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that k C� / e-�p Q� /-/C IL14 /;1 a,-1,4
....................... ..................................................................................
has permission to perform 10.(A..4v ..........................................
wiring in the building of ....... . ..........................................................
............ ... ...........
a! .... ....... ...... . North Andover, Mass.
........................ .................................. .
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Fee ... Lic. No -30z- P64' -
......... . ................. ....... . ........ ....... .. .... .... ....... . .
LE TR CAL INSPECT
Check #if -A 7 7 177
139!'1
Commonwealth of Massachusetts OfficialUseOnly
Department of Fire Services Permit No. Ow
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. I/o7] (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perfornied in accordance with the Massachusetts Electrical Code (�IEQ, 527 CMR 12.00
(PLEASE PRINT IN 17VK OR TYPEALL INFORMATION) Date: 5 , /s//s
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned ives n ice of his or her intention to perform the electrical work described below.
Location (Street & Numb , Y( -1,Rlieu LAA) -x -
Owner or Tenant
Owner's Address
Telephone No.
Is this permit in conjunction with a building permit? Yes 1XL No [] (Check Appropriate Box)
Purpose of BuildingJ�3-1AAVN,) Ne,,j 5ePVC— ik�~K Utility Authorization No.
Existing Service Amps volts
New Service Amps volts
Number of Feeders and Ampacity
Overhead Undgrd
Overhead Undgrd
No. of Meters
No. of Meters
Location and Nature of Proposed Electrical Work:" -TN -4AV,-1 Ne�./ 5ep;kr- �Qvvko
co,,*40) o*846- A ueu- Csp-c,*-
rnmnlpfin" nffhp fVInwi— mh7p — A, —h-,77.. th. T.—,t— �fffli—
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 o In-
Lrrnd. grnd.
No. o Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
J.N!!!Rl e r
I
I Tons
.............
I KW
................
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Municipal
Local El Connection El Other
No. of Dryers
Heating Appliances KW
Security Systems:*.
No. of Devices or Equivalent
No.. 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 hy the Inspector of Wires.
Estimated Value of Electrical Work- 0 (When required by municipal policy.)
-24-
Work to Start: C -M 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 [I BONDE] OTHER El (specify:)
Icerttfy, under thepains an penalties qfperjvry, that the in plication is true and
,formation on this ap complete.
FIRM NAME:
Licensee: Signature +WV-) QN�� LIC. NO.:
f- �c-" \^N� Vq( �J AV,.
(Ifapplicable, enter '�'xempl" in the license number line.) Bus. Tel. No.-,-)-%
Address: 8'- OLI&J/ J/,J- #2bY La-'-sU V�*k 61 X2- 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) El owner El owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE. S C1 6
ELECTRICAL PERMU NO. --�WSPECITONREPORT:
QI . "'S Tlowl.
. Frilss
e� 7-- Yalled—[ Re-inspectionrequireff($50.00)
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jkspectors3 commeAts:
, tl�01tweefors" Signature -no �fnftjals) Pate
2. WMAL XN83?Ypd6N,-
Passed — f Wed )RO-luspection required ($50.00) -
luppectoris, commenfs:
.44�
(fils&ctorsl Signature -nobitials) Szo
I)ate 'C
DOORTAGSARETOBE TD AND IEFT ON RITEM THE APXA TO BE INSPE CTEDISNOT
ACCESSIBLE AND ARE -INSPECTION OFM5 .0018TO)MCMRGED.
The Commonwealth ofMassaehusetts
Department of IndustrialAeeldents
I Congress Street, Suite 100
Boston,.M 02114-2017
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERAUTTING AUTHORITY.
Applicant Information Please Print LelZib
NaMe (Business/Organization/Individual):
Address:
City/State/Zip:
� &W�— Phone #:
Are you an employer? Check tfie appropriate box:
1.0 1 am.a. employer with . ... . employees (full and/or part-time).*
2�0 1 am a sole proprietor or partnership and have no employees working for me in
7 ---any capacity. [No workers' comp. insurance required.]
IF] I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4.FJ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
p � ietors with no employees.
ropr
5.FJ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
'these s�b-contractois fia�e employee's and have wo . rkers' comp. insurance.:
6.FJ We are a corporation and its officers have exercised their right of 'exemption per MGL c.
152, § 1(4), and Nye have.nck!,Dpploye�s. [No workers' comp. insurance required.]
Type of project (Tpquired):
7. n New construction
8. E Remodeling
9. Demolition
10 F1 Building addition
1l.FJ Electrical repairs or additions
12.E] Plumbing repairs or additions
13.E] Roof repairs
14.E] Other
*Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit fNs affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
t0intractors that check this box must�attached an additional sheet showing the name of the sub -contractors and state whether orn.ot, those entities have
employees. if the sub -contractors have employees, ley' must provide their workers' comp. policy number.
I am an employer that ispioviding workers' compensation insurancefor my employees.' Below is thepolicy andjob site
injormation.
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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
Ido herebMcertify under the ainsan penal ofperjuiy that the information provided above is true and correct.
r, U)
Signature.Mi=x= Date:
Official 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):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Person: Phone#:
Information an d 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 contraA,16f, h, ire,
expres's 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 ftu�tee 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 bd 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 oompletely, by checking - the,boxes that apply to your situation and, if
necessary, supply sub-'contractoi(s) name(s), address(es) and -phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ 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 fbi 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 o*r if you are required to obtain a workers'
compensatioti'policy, please call the Department at the number listed below. Self-in]sur6d companies sh,ould'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/ficense 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 Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
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PERMIT FOR G NSTALLATION
This certifies that .... ... ��? :": ...................
has permission for gas installation ...............
in the buildings of ... .........................
at North Andover, Mass.
Fee Lic. No. ci�. 3. ... ...
, GAS INSPECTOV,
Check # / 3 7 f -2
5887
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MASSACHUSETrS UNIMRMAPPLICATON FORPERNUr TO DO GAS FTrHNG
(Type or print) Date Ad 7
NORTH ANDOVER, MASSACHUSETTS
Building Locations
Permit #
Owner's Name Amount $
C4 -IL 6 / -�14 o Q Li
New Renovation Replacement 0- Plans Submitted 11
(Print or type)
Address
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Name of Licensed Plumber or Gas Fitter — 13 1) k --� --iz-
Check one: Certificate Installing Company
11 Corp.
E] Partner.
13-1�irm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 13- Noo
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy IT- Other type of indemnity 0 Bond 1:1
Owner's Insurance Waiver: I 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 0 Agent 13
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—.7 — Lily maL aij vt tim; uutaiib anu 1111MMULIU11 i nave suormueu kor emerea) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued or this application will be in
compliance with all pertinent provisions of the Massachusetts St 5?as Co i7r 1��(he
and Ch
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Title
PPROVED (OFFICE USE ONLY)
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§jgnature of Licensed Plumber Or Gas Fitter
Plumber /Z 3 (�
Gas Fitter LicenSe Number
Joumeyman
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13-1�irm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 13- Noo
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy IT- Other type of indemnity 0 Bond 1:1
Owner's Insurance Waiver: I 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 0 Agent 13
--I- - - �. - - .... .. - . - - � -
—.7 — Lily maL aij vt tim; uutaiib anu 1111MMULIU11 i nave suormueu kor emerea) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued or this application will be in
compliance with all pertinent provisions of the Massachusetts St 5?as Co i7r 1��(he
and Ch
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Title
PPROVED (OFFICE USE ONLY)
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§jgnature of Licensed Plumber Or Gas Fitter
Plumber /Z 3 (�
Gas Fitter LicenSe Number
Joumeyman
DATE:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
AC (example: left front of house)
61c U
DATE OF PUMPING: J()L q -!D k QUANTITY PUMPED—�S�
CESSPOOL: NO YYES SEPTIC TANK: NO
NATURE OF SERVICE: ROUTINE YIEMERGENCY
OBSfERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY -
COMMENTS:
GALLONS
YES ',//
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK.
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO: 6, L - � , h -