The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 3 MILLPOND 4/30/2018C) CD C) Y) C) DateJAAI.677 .................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ................................... ...has permission for gas in 11 .... .. ..... ...................................................... r., atio. in the buildings if " f--) ................................................................................................................... at ... . . ......... ........... ...................................... . North Andover, Mass. Fee. ...... Lic. No. ................... ..................................................................... GASINSPECTOR Chock I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'A Y� MA DATE PERMIT# JOBSITEADDRESS OWNER'S NAME r--,r- GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL �r PRINT CLEARLY NEW- El RENOVATION: El REPLACEMENTM� PLANS SUBMITTED: YES F1 NO 0 V-1 APPLIANCES -1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNAnE -GENERATOR GRILLE INFRARED HEATER LABORATORYCOCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER, ROqE TOP UNIT TEVr UNIT HEATER UNVt,NTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current Ilablift nsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING -THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E] OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER- I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement CHECKONEONLY: OWNER E3 AGENT El SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with 11 P rtinent-Drovision-ofthe Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER �Z LICENSE # SIGNATURE NAME rVj C,4� MP W' MGF E], JP E] JGF [] LPGI CORPORATION [j # PARTNERSHIP n # LLC # COMPANY NAME 4 �kf" &,c - P) tAk ADD RESS LA, CITY- STATE-��M 75 P, TEL .FAX CELL EMAIL 0 . I I /M10 I ,, � - � �:' -1. - - - .. i' �.:, ' ��i; i�� . �, z V1. o LU LU LU LU U) z 0 CL a- 4 L 12 LU LL. 0 �-v z CA z 9L( EDWARD J MATHEWS III (PL) 24 WEST WOODCREST DR MELROSE MA 02176-3414 IMPORTANT NOTICE PERMITS FOR PLUMBING AND GAS FITTING INSTALLATIONS ON STATE OWNED OR USED FACILITIES MUST BE FILED AT THE OFFICE OF THE STATE BOARD. Fold, Then Detach Along All Perforat ons ... .. ....... ... .. .... ; 4" M 1 The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Pluiiibers. TO BE FILED WITH TIRE PERNUTTING AUTHORITY. Name (Business/Organization/Individual): (I Address: 2VQ LV. LA_,1L>VJCr—CS4_ City/State/Zip: 6k W — Phone#:— —39 IS Are you an employer? Check the appropriate box: '3 mp Im. I am a employer with 1 , e loyees (full and/or part-time).* 2.FJ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. n I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4Q 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 proprietors with no employees. 5.FJ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.: 6.FJ we are a corporation and its officers have exercised their right oflexemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7, New construction 8. Remodeling 9. F1 Demolition 10 0 Building addition 11. F-1 Electrical repairs or additions 12. F1 Plumbing repairs or additions 13. E] Roof repairs 14. E] Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation 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. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. Ifthe sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurancefor my employees. Below is thepolicy andjob site information. Insurance Company Name: Policy 4 or Self -ins. Lic. ""'J _Z, Expiration Date: �'// 1-7 //1(, Job Site Address: -9 City/State/Zip: IV04J -),)10 V, r Attach a copy of the workers' com�ensdtion 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. I do hereby certify y4 fr thepains an�p d _au aLdes-vf—p—erj-u-" at th e inform atio n pro vided ab o ve iy tru e an d correct. Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # I-, 5-13 bh-' Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires -all employers to providdworkers' compensation for their e' mployees. 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 writteh,," 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 ofa deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, emplo y-ing-e m-ployees. 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, --MOL ch�-Rter 152, § - g5CQ)_ states 'Weither the commoriwealff- - or any of its _ poiii-tical subdivisions shall n enter into any 60'Intract. for the performance of public work until acceptable bvidence 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 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-�hon`l�. be returned to the city.or tdwh'that'the iaip'plicati.on for the -permit or license -is being requested, not the Department 0`f - .Industrial Accidents. Shouldy�ou 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' com parries 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 "lob Site Address" the -applicant should write-%ll,r6C`&i6ns`mz`= � ` %; -_ - (city or ciai stamped or marked by the city or town may be provided to the town)." A copy of the affidavit-thathas be6n 6`ffi fly" ` _' - i applicant as proof that a valid affidavit is on file for ftiture 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: Conimonwealth of Massachusetts Departmentof Industrial Accidents I Congress Street, Suite,100, Boston, MA 02114-2017 Tel. # 6177727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Date.... .......................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...................... ............................. 0� ................ S ......... 6 has permission for gas installation ..... .... inthe buildings of ................................................................................. at ......... 3 ........... ....... . ... ...... North Andover, Mass. Fee ... 3(,o ... Lic. No. . ... .......... GASINSPECTOR Check #21 �I 9641 C-1 IF� VYN,- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kip A CITY PERMIT# - !�_ ____j MA DATE JOBSITE ADDRESS j OWNE41S AME G(ONNER ADDRESS J TEL[ FAX TYPE OR OCCUPANCYTYPE COMMERCIALE] EDUCATIONAL RESIDENTIAL PRINT CLEARILY NEW:F_1 RENOVATION: REPLACEMENT PLANS SUBMITTED: YESF___jj NOE] APPLIANCES I FLOORS- BSM 1 2 3 4 5 6 7 8 9— 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER . . . . . . . . . . COOK STOVE I J ... . ..... DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR -,"I ____j __J GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOF TOP U NIT TEST UNIT HEATER LINVENTED ROOM HEATER WATER HEATER _11-1 - - - - - - - - - - .......... . .............. ........ ..... . .... . . . . . . . . . . . . INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YESP�O I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ;a OTHER TYPE INDEMNITY E] BOND Ell OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT E-31 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliar i"alwertin ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME SIGNATURE LICENSE #ajj� IVIP' MGF EjI JP Ej JGF LPGI CORPORATION D# L= PARTNERSHIP E__11# LLC E3# COMPANY NAMEI ga�rg_ L ADDRESS CITY STATE�ZIP !��/_:ZOTEL FAxL-----Jl CELL AIL pr rA wI u 0 El z rA P4 u LLI P-1 F - of) U) r4 < LLI CO) w CO z 0 (L LLI LL rf) 0 OU Dlvi��f Professional Licensure: License Search http://license.reg.state.ma.us/public/pubLicenseQ.asp?board—cod The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure whes.Gov I Mass.Gav Home State Agencies A-ZToples Home) Division of Professional Licensure ) Check A Professional License By the Division of Professional Licensure LICENSEE Name: EDWARD J. MATHEWS Ill. MELROSE, MA NEW SEARCH **This Licensee has additional Licenses, click here to view them.** Licensing Board: PLUMBERS Et GASFITTERS License Type: MASTER PLUMBER License Number: 15180 Status: CURRENT Expiration Date: 5/11/20116 Issue Date: 11/28/2006 Exam Date: 11/28/2006 School: This web site displays disciptinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Tuesday, October 21, 2014 at 9:37:13 AM. 0 2007-2011 Commonweafth of Massachusetts I ONLINESERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency i0ore ... REFERENCES& RELATED INFO Disclaimer Regarding Website License Searches Glossary of License Status Codes !vote... I �f I 10/11 /70 14 9- 17 / rA n JF % . I "W ........... Date .... 10846 .5z/" / TOWN OF NORTH ANDOVER PERMIT FORPLUMBING This certifies,t,hat .... , jk� ............................................................... has perussion to perform ..... ......... rerr'...A.- ......... ..... . .. ......... plumbing in the buildin s of Q./s . . ............... .......... i ................... ................... North Andover, Mass. ' i C� b F e e ..... Lic No . ............... ... ................................ PLUMBING INSPECTOR Check it L MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK I ) CITY MA DATE I/ PERMIT# f JOBSITE ADDRESS OWNER'S NAME [� � � �� 1'n- 11 OWNER ADDRESS TELL FAX P --11 TYPE OR OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIALa-' PRINT &7 CLEARLY NEW: RENOVATION: REPLACEMENT: 4r PLANS SUBMITTED: YES Ell NODI FIATFRES I FLOOR- FM- FW- M I W-- FPW M F9 -W FN -W M FM FM- FW- FW- r -W- I W K FF -W- FW- MIN M F M-- FN -K WN FW- FM- FM- FW- F M-- FW -W 1-0-M IN N FP -W FM- 10-0- FW -K F M-- FM -W FW- FM- FN -K FW- FW- W FW- FEW I NOW TA . IN -01 — F -F- -F-F-F-M-FM-MF-M-FM-FM-K-F-M-FM- MW M- FM M W DEDICATED WATER RECYCLE SYSTEM DRINKING FOUNTAIN 00-0- FUNFIMMMOMFOMMMMOOMMIMM - -F-F-F- - -F--F- F4411) DISP#SER F4 W- FX -K FN -K W- FW- FWK FW- FM- FM- FW- FM FW- W I W-- FW -K FLOOR /AREA DRAIN INTERCEPTOR (INTERIOR)__ F W ---F-F-F-F-F-F-[-F F 4 KITCHEN SINK ___FW11WrWWWWWWWWMFWKFM1 F �-- F �-- F�- F�- F �-- F�- I �-- F �-- F �-- F �-- I �-- F �-- F�- I �-- r �-- SHOWER STALL SERVICE / MOP SINK TOILET URINAL ' MACHINE CONNECTION WATERAEATER ALL TYPES WATER OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Wl NO D-1 IF YOU CHECKED YES, PLEASE INDICATE TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER F-11 AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application Will be in compliancg_with all P-e-djuet. . . f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f�>Jpn 0 PLUMBER'S NAME 4U0,&&e k,, -S ---11LICENSE# SIGNATURE mp�a JP 01 CORPORATIONFlj# PARTNERSHIP01# LLC D� COMPANYVAME ADDRESS -1cfW-1 I - CITY STATE ZIP TEL FAX I CELL EMAI 0 I El z Lij m Cd LU LL. 7 ,p The Commonwealth ofMassachusetts Department of IndustriqlAccidints Office of Investigations 600 Washington Street Boston, MA 02111 W www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/ContractorsfElectriciansfrIumbers Applicant Information Please Print Lealbly Name (Business/Organization/Individual): �Y,- - b , Address: LAJ , 1-4 J t-3 A City/State/Zip: -,Me 11pe, Phone #: 9? �)-P I - Are you an employer? Che e appropriate box: LM I am a employer with 4. El I am a general contractor and I employees (fult and/or part-time).* have hired the sub -contractors 2.11 1 am a sole) proprietor or partner- listed on the attached sheet I ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. El We are a corporation and its required.] officers have exercised their 3. 1 am a homeowner doing all work E] right of exemption per MGL myself. [No workers' comp. c. 152, § 1 (4), and we have no insurance required.] t employqe's. [No workers' comp. insurance required Type of project (required): 6. F1 New Coll ' struction 7. 0 Remodeling 8. E] Demolition 9. F1 Building addition 10. F1 Electrical repairs or additions 11. F1 Plumbing repairs or additions 12.F] Roof repairs 1311 other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they P�e doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that isproviding workers'compensation insurancefor my employees. Below is thepolicy andjoh site information. Insurance Company Name:. C< Policy # or Self -ins. Lic. Expiration Date: Job Site Address:- 3 p"I. Pity/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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 andlor otie�-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 h ereby c erfify u n der flzxp a in s an dp en aldes ofp erju jy th at th e inform a don p To vided a b lov P_J is ir d correct SiMature: Date: Z�/ Phone#: 39 IS Official use only. Do not write in Mis area, to he completed by c4 or town official. City or Town: PermitfLicense N Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone M: Information and Instruction' -s 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 ofhire, express or implied, oral or written." An employerlis defined as "an individual, partnership, association, corporation or other legal entity, or any twc) or more of the foregoing engaged in ajoint 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-contractor(s) name(s), address(es) and phone riumber(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 maybe submitted to the Department of Industrial Accidents for confirruationof 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. I , t 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. Pleas ' e 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 now affidavit must be fille�d 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 p* ermit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations 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 Mmssach-usetts Department ofladustrial Accidents Office eflovestigatiom - 600 Washington Street Boston, MA 02111 Tel, 0 617-727-4900 oxt. 406 or 1-877rMASSAFE Revised 5-26-05 Fax # 617-727-7749 -wwwmass.gov/dia Date.A.11.�'.I.I.+ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies tha!t� J'e—I VVk_I0..S .......... ....................................... : ................. .............. ...... -has permission to perform ....... ...... M .. 04.1.e ... ( ................. wmng iij the building of ............... ........................................................................................... at .............................................. ........................................................ , o h Andover, Mass. Fee .... F_P�_ Lic. No, .............. ...... ... E c ]CAL NSP CTO Check it 12 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only PermitNo. Occupancy and Fee Checked [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NMC), 527 CMR 12.00 (PLE,4SEPRDVT1NMK OR TYPE-4LL RWORALMOA9 Date: I/ —7-e — 1 '74 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her mit7tion to perform the electrical work described below. Location (Street & Number) 3 M, I ( Po4 Owner or Tenant �[ ( t q (-I C7/1 a W� 1- -7 Telephone No.97 k - 571 Owner's Address Is this permit in- conjunction with a building permit? Yes ET No [I (Check Appropriate Box) Purpose of Building q, C 5 r �c -1 6 c Utility Authorization No. - Existing Service Amps volts New Service Amps Volts Number of Feeders and Ampacity Overhead [J Undgrd [J Overhead [J Undgrd [J No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: e c f_,e 7,4, clt 7 e -Y I's T, L 1"C LA v7LA 'F. - F i,,, ' & -, c- Comnletion ofthe followine table mav be waived bv the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. o Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators . KVA No. of Luminaires Swimming Pool Above n In- El grnd. grnd. mergency Lighting BatteryUnits No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS IN'o. 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 HeatPump, Totals: � N1 .......... IKE- No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local E] Municippl El Other Connection 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: J Attach additional detail ifdesired, or as required by the Inspector of 07res. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with I�MC 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 operation7' 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. CBECK ONE: INSURANCE Y BOND F1 OTBER F] (Specify:) I certify, un def th e P ndpenalties ofperju I th at the information on this application is true and complete. 1 :71 . LIC. NO. 7 FIRM NAME. "4 -e i v-cA I Licensee: "Tam -el -7-�,, I., ( Signature LIC. NO.: 9- -7 9 9 S— (Ifapplicable, enter "exempt" in the license number line) Bus. Tel. No. - Address: 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 requiredbylaw. Byrny signature below, I hereby waive this requirement. lamth6(che one) 1:1 owner E] owner'sMent. Owner/Agent PERMIT FEE.- $ Signature Telephone No. ,"t 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the 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 J 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 conceming 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 0 • Permit Extension Act — Permit/Date Closed: Trench Inspection Pass IN Failed Re- Inspection Required ($.) D Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass [N Failed Re- Inspection Required ($.) D Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass EN Failed Re- Inspection Required ($.) D Inspectors Comments: Inspectors Signature: Date: 4r ROUGH INSPWI N: Pass IN K, Failed Re- Inspection Required El Inspectors ComVmVts: Inspectors Signature: Date: FINAL INSPE$61ON: Pass F?1 V Failed Re- Inspection Required El Inspectors Comments: 01 Inspectors Signature: IliMezo, Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com The Commonwealth ofMassachusefts Department oflndustriqlAccWnts Office of Investigations 600 Washington Street Boston., MA 02111 www.mass.govIdla Workers' Compensation Insurance Affidavit: Builders/ContractorsfFle,ctriciansfPlumbers Applicant Information --Please Print Ley -Lb r- 7__ Name (Business/Organizationgndividual): J ct- Vkl Address: 3 tate/Zip: /-V Phone#: Are you an employer? Check the appropriate box; - Typo of project (required): 1. rl I am a employer with _ 4- El I am a general contractor and 1 6. E] Now construction employees (full and/or part-time) have hired the sub-cofitractors listed on the attached sheet. t 7. E] Remodeling 2. 0,P6m_ a sole proprietor or partner- ship and'have no employees These sub -contractors have 8. [] Demolition working for me in any capacity. workers' comp. insurance. 9. El Building addition [No workers' comp. insurance 5. We are a corporation and its 10.n Electrical repairs or additions required.] 3. El I am a homeowner doing all work officers have exercised their right of exemption per MOL I LEI Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1 (4), and we have no 12.Q Roof repairs insurance required.) employees. [No workers' 13.n Other comp. insurance requiredJ 'Any applicant that checks box4f must also fill outthe section bel6wshowingtheir workers' compensation policy information. T Homeowners who submit this affidavit indicating they Die doing all work and then hire outside contractors must submit anew affidavit indicating such. tContrar,tors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that isproviding workers I com pensation insurancefor my employees. Below is thepolicy antljoh site information. Insurance Company Policy # or Self -ins. Lie. ff: Expiration Date: Citv/State/Zip: Job Site Address: Attach a copy of the workers' compensation -policy declaration page (showing the p . dlicy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as wellas civilpenalties in the form of a STOP -WORK ORDER and a fine ofup 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 h'er�hy certio under thepains andpenalties ofperjury that the information provided above is true and correct. Date: Z7 R4o-nnfim-o )>��, / / �_ �. o . - . Official use only. Do not write in this area, to be completed by city or town offl-cla7 Cifv or Town: -PermittLicense 9 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Vn-nfnPVP,-.r.Qnn! - Phone 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance-witir the provisions of M.G.L. c. 143, § 3L, the 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 20 10 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 extending1hrough August 15, 2012. • Rule 8 — Permit/Date Closed: Note: Reapply for new permit El • Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed Re- Inspection Required ($.) El Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required 0 Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re- Inspection Required 0 Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re- Inspection Required 0 Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass F?] Failed M Re- Inspection Required 0 Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com " -X �qk,�G'OMMONWEA . LTH OF MASS,'A--C�,-HOSE-1.7.S�'.--"-.'I