HomeMy WebLinkAboutMiscellaneous - 30 GRAY STREET 4/30/2018 (2)Ul
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Date.515..I.o ..................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that �.Txj .... f A. -I / 21-1 Of.de-4.0 j
...... .... ......... ... . ..... . .... ............ .
has permission to perform .
.......... ........................................... .......
winng in the building of ..... e- �0
.......................... . ...............................................................
at ......... S ......... 6 ...... .................................. /.—� North Andover, Mass.
Fee .... ........... Lic. No.218,33 H4,- ' -4
................. ........ . .......... Z�.i� �.. . ...... 11 ..................... .... .. ....
T-
ECMCAL SPECrOR
Check # V
P)P
tv\
N,
N,
Official Use P,�y
Commonwealth of Massachusetts
Permit No U
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.lm] aeaveblnk)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
(PLF All work to be perfonned in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00
_4S
E PRfl VT IN HK OR TYPE A LL R WOR MA TIOA9 Date:
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) 30 GeTIlly
Owner or Tenant Telephone No.
Owner's Address
Is this permit in'conj unction with a building permit? Yes E] (Check Appropriate Box)
Purpose of Building /ZtS- r Utility Authorization No. 1(of 5 Z �2-'
Existing Service /00 Amps /ZQ /?-((,-J Volts Overhea4-E] UndgrdF] No. of Meters -Z
New Servic '26tz Amps aQ /!�M)Volts Overhead UndgrdE1 No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: kle, Od&C.Q ��eeZ4 ZA.- jW1
4Tnd S-07aj!jj�- 4&LecAs-r
Completion of the following table may be waived by the Inspector of Wires.
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 Ei In-
grnd. grnd. El
NO-50TEmergency Lighting
Battei�y Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
JN'o. of Zones
No. of Switches
No. of G2s Burners
No. of Detection 2nd
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
I Number
I'-- -1
I Toj!�
***
j.KW ...........
...........
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:
,4dach additional detail ifdesired, or as reqtdred by the Inspector of 07res.
Estimated Value of El ork: (When required by municipal policy.)
,f
t,
Work to Start: f) / y Inspections to be requested in accordance with NIEC Rule 10, and upon completion.
INSURANCE 0 R Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provide- Ir6of of liability insurance including "completed operatioW' coverage or its substantial equivalent. The
1W
undersigned certifies that sucb coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSUIRANCE �a BONDEI OTBEREI (Specify:)
I certify, tin der th e pH* s an d p en alties ofp erjury, h at th e inform ation on th is applica don is tru e an d complete.
FIRM NAME: LIC. NO.:
I >-
Signature A2t��
LIC. NO.:. zin
Licensee: �3A
(If applicable,'enler-'�pc'mp'�'t"'rn the lzcf nse v ber line.) Bus. Tel. No.:
'? �> Alt. Tel. No.:!7�
Address: 0 . t --,c - q 11jakZkC a. ��r
*Per M.G.L c. 141, s. 57-6T,s-ecurity wo—rk requIres Departnient of Public tdety "S" License: Lic. No.
OWNER'S INSURANCE WAYVER: 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 (che one)E] owner E] owner's agent.
Owner/Agent I &RWTFEE.-
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
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.
El 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.
0 Rule 8 — Permit/Date Closed: Note: Reapply for new permit 0
0 Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICEZKSPECTION:
Pass
Failed
Re- Inspection Required El
Inspectors Comments:
Inspectors Signature:
etvyl
411�'
Date:
PARTIAL ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass X
Failed
Re- Inspection Required 0
Inspectors Commeqn
Inspectors Signature:
Date:
FINAL IN
AICTION:
Passw",
Failed EN
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
4_1
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
The Commonwealth of Massachusetts
D7 Department oflndustdqlAccldi�ts
Office of Investigations
600 Washington Street
Boston., MA 02111
Ut www.mass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians[Plumbers
CitylStatelZip: (A 14 e�
Are you an employer? Check the appropriate box:
1. F1 I am a employer with
4. El I am a general contractor and I
employees (fall and/or part-time).*
have hired the sub -contractors
2-94 �arn a sole. proprietor or partner-
listed on the attached sheet
- shi—p"tind'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. El I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. E] New construction
7.,gRemodeling
8. F1 Demolition
9. E] Building addition
_1�.�lectrical repairs or additions
ILE] Plumbing repairs or additions
12.E] Roof repairs
13.Fi Other
!Any applicant that checks box#1 must also fill out the section bel6wshowhig their workers' componsationpolicy information.
T -Homeowners who submit this affidavit indicating they ai-e doing all work and then hire outside contractors must submit anew 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 insuranceformy employees. Below is thepolicy andjoh site
information.
Insurance Company Name
Policy # or Self -ins. Lie. #:AMAcx(1_s&z Expiration Date:
Job Site Address-,, Ko
Pity/State/Zip:
Attach a copy of the workers' compdsation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requireclunder Section 25A of MGL c. 152 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
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 th surance coverage verification.
Z Z
Idolierebyceh&4n:der7,7ilairan:d:p:enaZesofperjury=t7iiattl, informationpTovided above ' true deorrect.
Simature: Date:
Phone#: 7 7(�371
Official use only. Do not write in this area, to he completed by c4 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
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 employee is defined as "....every person in the service of another under any contract ofhire,
express or implied, oral or written.,,
An empluel;is defined as "an individual, partnership, association, corporation or other legal entity, or any two 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 subdivi - sions 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 (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 for confirm�ation of insurance coverage. Also be sure to sign and date the affidavit. 11e affidavit should
be retained to the city or town that thei 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'Iegibly. 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 (ifnecessary) 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 ii 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 p* ermit to bum 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 Mo hp
�sso,c isetts
Department oMdustrial Accidents
Ofte offavestigatio.ns
600 Wasbingtou Sixeet
Boston, MA 02111
Tel, # 617-727-4900 at 406 or 1-877,MASSAFE
Revised 5-26-05 Fax # 617-727-7749
__wwvvmass,gov1dia
0
I
21833-A
License No.
Co
Division
Board ot
RYAN
4 LISA
NORTI-
Master
07/31/,
ExPiration Date.
—�Ozo
Serial No.
Date .... / [--/ L/— //
...........................
TOWN OF NORTH ANDOVER
PERMIT IFOR WIRING
This certifies that ............. 2.)
.................... ... K .....................
has permission to perform ....... 4-0!!kz--IP41 ..................................................
wiring in the building of ....... -7
........................... ( ..............................................
at ........
....... 5-i . ......................... . Aoqh Andover, Mass.
Fee ... 3 Lic. No. !.L/.i(0:3 ............
-i�AIC �1�;�E
C h e c k # 357-7�(,
10472
1 4
.C-\
SHEREM -ammm"
C
BOARD OF FIRE PREVENTION REGULATIONS
1 14� )i wy
Permit No.
OcmllancY and Fee Checked
- V071 (1cambiwir) I
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
AD work to be PafbnnW in accor&we with Me Mamchowft BMW
Mal CO& (hnX
(PLWEPRhWbVflff OR TYPE AUMFORM �, �27 CMR 12-00
City or Town oh .4 77OA9 Date: AV( I
By this application the To the Inspector of Wires. -
gives notice of is or her i��on too pe&nu the electrical work described below.
Location (Street & Number) qo -, A4-1, -<r-
Owner-orTenaut '0 S 'W
Owner'sAddress Telephone No.
Is this Per2ft in conjunction with a building perndt9 yes ED"— No (Check Appropriate Box)
Punme of Utift Authorization No.
Existing Service Amps volts Overhead `U11dgrd No� of Meters
New Service Amps ____�_Volts Overhead U-ndgrd No. of met..
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
No. of Recessed I
n
we dol.1wr
taffe way be imm
NO, Of CdL-Su3p. (Paddle) Fans fqo' of
Transformers KVA
No. of Luminaire Outlets
No.of Hot Tabs Generators KVA
No. of Luminaires
swimming Pool
140. of CY
d. Krad.
BgYpELUnits
�No. of Receptacle Outlets
No. of ON Burners
FIRE
No. of -switches
N&. of Gas Burners
NK Of Veteetion and
-Total
Initiating Devices
No. of Ranges
No. of Air Cond, Tons
No. of Alerting Devices
No. of Waste Disposers
P
No. 4--Seff-CouWned
SpacdArea Heating KW
Detection/Alerting Devices
No. of Dishwashers
CIP
0 O'ber
'Mao comim n
No. of Dryers
Beating Appliances KW.
Secarr% Systems:*
No. of Water
Heaters KW
NO. of No.
MO. f Devices or Equivalent
DataVVU-ing.
signs Ballasts
N& of Devices or Equivalent
No. flydromassage Bathtubs
No- of Motors Total HP
Teleco unications
No. of Devicess or ent
OTHER:
Estinxted value of sectricai work: awnamuaemgamre4cratraywmdbyL4elwpeaorofffnleL
, (When rapnred by municipal policy)
WO,k to Stalt Inspectiow to be requested in accordance with MEC Rule 10, and upon complefior,
INSURANC9 COVERAGE. Unlm wanvd by the owner. W permit for the performanceof electrical work may issue .1.
the limsce prarvides; proof of liability hisurance; including -COraphftd opetation" coverage or its substantial equivaleuL 11m
undersigned certifim that such coverage is in ibrm and has aNhited proof of am to ffic permit issaing offim
CHECK ONE INSURANCE 5b BOND [] MIM rJ
I cerI6, under thepains andpewakfes ofpedwy, thal the Worwaojz an &s
ithiv ;';cag ibs hwe and coaVlete.
FIRM NAME: 1-7&j i ED jF�(_ C�(-_Tkv CAL LIC. NO.!
Uccum: JRAV 10
kA Signatare LIC -NO.- "46-3
ffaWicablk emer "me%w - in &e Acmse =mber rma) , - 7
Address: -1 W J�KpouS_ J Bus. Tel. No., q 7 11 - QQ �L
8 t -#V" -r 1!�—; — 1"114-AO-Mvem " Alt. Tel. No. -
Ver bLGJ c. 147, & 57-61, security work minires; Dqwtmmt of Public Safety "S- Licens= Lic. No.
OWNER'S INSURANCE WAIVER: I ain aware that the Licensee does �ot ham the liability insurance coverage normally
required by law- By my signature belOw, I hCrebY waive this requirement. I am the (check one) 11 owner ownees ageL
Owner/Agent
signature Telephone No. [PERAHTPEE;
7�^Coa
-1
i
Are you an employer? Check the appropriate box:
The Commonweafth ofMassachuse&
1. 1 am a employer with 8
Department ofindustrWAccidents
Office of Invay*afions
have hired the sub-contiactors
600 Washington Street
2. 1 am a sole proprietor or partner-
Boston, AM 02111
7- [] Remodeling
wwwma&&gov1dia
W&Akiii'Vo_mpensation Insurance Affidavit.- Builders/ContractorsAElectricians/Plumbers
Apyticant Inforniation
Please Print LegibW
Name (BusineWOrganizationAndividual): Q/W(Q ELECTP,1CAL_ C0kTgAC-TtAG LL -C,
Address:
9-7 BELVIDi-4-F !�-i
City/state/zip:_N0R,rN&v0v,5,iZ ft, 0105' phone#:
Are you an employer? Check the appropriate box:
Type of project (required):
1. 1 am a employer with 8
4. F1 I am a general contractor and 1
employees (fijll andfor part4ime)-*
have hired the sub-contiactors
6. E] New construction
2. 1 am a sole proprietor or partner-
listed on the attached sheeL
7- [] Remodeling
ship and have no employees
These sub -contractors have
8-E] Demolition
working for me in any capacity-
employees and have workers'
9. E] Building addition
[No workers' comp. insurance
comp. insurance.:
required-]
5. We are a corporation and its
I O.E] Electrical repairs or additions
3. El I am a homeowner doing all work
officers have exercised their
I LEI Plumbing repairs or additions
myself [No workers' comp.
right of exemption per MGL
12.F] Roof repairs
insurance requiredL] t
c. 152, § 1(4), and we have no
13-[-] Other
employees- [No workers'
comp. ins�rance required.]
*Any pplican, that checks box #1 must also fill out the section below showing their workere compensation policy information.
t H..L., who submit this affidavit inidicating they are doing all work and then hire outside contractors num submit a new affidavit indicating such.
;Contractors dud check this box must aftached an additional sheet showing the name of the sub-convactors and state whether or not those entmes have
employces- If the sub-conuactors have employees, they must provide their workers' comp. policy number.
I am an enrloyer that isprovl&ng worken'compemadon insurancefor my employm. Below is thepoficy andiob site
infoYmatlon-
InsuranceCompanyName-_ 4movreg AwtepzicAH
Policy # or Self -ins. Lic. #: W Z' tQ * 5-0 9 0 1 -7 ?__ Expiration Date: 3- (- IR
� Job Site
City/State/Zip Al", /10- :xv/ �—
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration dat4
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 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
I do hereby cen* u I enafties ofpedury &w the informadon provkW abo * true and coffect.
Shmature: 7t
L.111- , 4, 1 �,-2 1 1 -
Phone It- 9 16 - (, e 2,/
ase only. Donot write in Ms area� to be completed by c&y or town officiaL
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City1rown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone
7 4
0
CHUS
This certifies that
Date.*e. 71w
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
An
................
has permission to perform
plumbing in the buildings of ... v Ole
a t 6?m �( . S 7-- ............... ;op—
...................... I Noph Andover, Mass.
Fee. Lie. No. . A�4�� . J �X 44-�l
PLUMBING INSPECTOR
Check # IVS�� &YX?
0
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLLTMBIN
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location
New 1:1 Renovation 11
Owners Name
Type of Occupancy
Replacement
FIXTLJRES
Date
Perm�t—#
Amount
Plans Submitted Yes No M
. 0 � ACV
(Print or type)
Installing Company Name
Address
Name of Licensed Plumber:
A1111111h4 �
Check
C d,�Fertificate
orp. 7
Partner.
Firm/Co.
Insurance Coverage: dicate tne rive or insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity El 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 1:1 Agent n
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 performed under Permit Issued for this application will be in
compliance with all pertinent pq�?Isiqns of the Massacpusetts S�pte Plumbingjfodjr�n
1 4 A . lo — d Chapter 142 of the General Laws.
01 10.
'/j/Type o lumbing License
own 771cense NUM177' Master '/ /Joumeyman
OVED (OFFICE USE ONLY