HomeMy WebLinkAboutMiscellaneous - 30 High Street Suite 241A
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Date ... 7�b -76-1
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
I—
This certifies that
has permission to perform ....... ...... .........................
wiring in the building of Pe c,-- L-
.......................................................
Sr5� 16
at . ..... I North Andover, Mass.
. ........ ............ ...............................
I Q-11
Fee.1,2'5 .. ........ Lic. No. . . ...................... E*C" T-R-I'C' * A** L** *J* 'N' *S*'P' E -C- T**O"R*
Check # IQ6 �
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Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
PermitNo.- �;�->\C�3 —
occupancy and Fee Checked
[Rev- 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (NBC) 27CMR12.00
(PLE-4SEPRJWT1NMK OR TYPEALL NFORMTION) Date: -3h 111A
City or Town of. NORTH ANDOVER To the lnsp�ctor lo� W—ires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 50 b I q k K 'ir-&CS- ( RC,6) rck-r,-5 -rq1CPCr
r- Tel hone No Acroc
Owner or Tenant
Owner's Address
Is this permit in"conj unction with a building permit9 Yes Ff No (Check Appropriate Box)
Purpose of Building A6 1 (0 _ Utility Authorization No.
Existing Service Amps Volts OverheadF] Undgrd n No. of Meters
New Service Amps Volts Overhead [] Undgrd [I No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Cnmnlptinn nfthp fnllnwing table ma -v be waived bv the Inspector of Wires.
No. of Recessed Luminaires
No. of Cell.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above Ei In- D
Swimming Pool ' d.
grnd. grn.
No. of Emergency Li ing
Battey Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
IN'o. of Zones
No. of8witches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
Heat Pump
I Number
I ToA�
No. of Self -Contained
No. of Waste Disposers
Totals:
I.KW ...........
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
--I Municipal
'Local D Other
El Connection
No. of Dryers
Heating Appliances KW
Tecurity —Systems.*
No. of Devices or Eguivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
I No. of Devices or Equivalent
No. Hydromassage Bathtubs
of Motors Total HP
Telecommunications Wiring: Z.L-,-"
No. of Devices or Equi4lent
OTHER: 10 6 U il e,
()(D Attach additional detail if desired, or as required by the inspector oj n, 1res.
Estimated Value of Electrical *Work- tQ QW, (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with NIEC 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 operationP 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.
CBECY, ONE: INSURANCE [I BOND[--] OTBEREJ (Specify:)
I certify, under the,pq� andpenalties ofperjury, that fite information on this application is true and complete.
-tri -I:n- (, LIC. NO.:
FIRMNAME-
Licensee: t 6,cw-ro Signature"- LIC. NO.:
(1fapplicable, enter '�exenpt" in (he lken,e�,�Mber line Bus. Tel. No. '
L VZ , - INUL7
4
f j
Address: j Q--1 -6jr� Alt. Tel. No. -
*PerM.G.Lc. 147, s. 57-61, secuji*� work requires Depaltment of Public Safety "S" License: Lie. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coveragenormally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) [j owner [j owner's agent.
Owner/Agent
Signature Telephone No. FPv?MITFEE.-$
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 sball.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.
• Rule 8 - Permit/Date Closed: Note: Reapply for new permit 0
• Permit Extension Act - Permit/Date Closed:
Trench Inspection
Pass EN
Failed Id
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPiCTION:
Pass M ( Z
Failed
Re- Inspection Required 0
Inspectors Comments:
4
Inspectors Signature:
Date:
FINAL INSYECTION:
Pass M -/
Failed
Re- Inspection Required 0
Inspectors Comments:
-4 0
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
11
,I
.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/Plumbers.
TO BE FILED WITH THE PERNUTTING AUTHORITY.
Applicant Information Please Print Lel4ib
Name (Business/Organization/Individual):_
Address: 16 ui4�lie_
city/state/zip:,5kvcw�,WO,MA-0(5-4S Phone#: Sc)'R 733-'?' Cc-t�
Are you an employer? Check the app iopriate box:
I.FlIamaemployerwith employees (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
4.F] I am a homeowner and will be hiring contractors to conduct all work on my property. 1will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
S. FJ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have en�ployee's and have workers' comp. insurance.T
6.FJ We are a corporation and its officers have exercised their right oflexemption per MGL c.
' ' "'I' e
152, § 1(4), and we have no. emp oy e,s. [No workers' comp. insurance required.]
Type of project (Tequired):
7. F1 New construction
8. F] Remodeling
9. n Demolition
10 Building addition
11. F1 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 theirworkers' compensation policy inform.ation.
t
I Homeowners who submif 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 orriot those entities have
employees. if the sub-codtractors have employees, 1hey must provide their workers' comp. policy number.
I am an employer th at is pro viding w orkers' comp ensation insu ran cefor my employees. Below is th e p olicy an djob site
information.
Insurance Company N
Policy # or Self -ins. Lie. #:
u( UC4,
Expiration Date:
Job Site Address: 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.
I do hereby certify unfi&q the paks andpenalties ofpeijuiy that the information provided above is true and correct.
07
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
31,71/6
Issuing Authority (circle one): 'I
1. ]Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact
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 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 ajoint enterprise, and including the legal representativesof 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 b6 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."
pplicants
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 fb� confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city pr town that the application for the permit or license is being requested, not the De'
partment of
Industrial Accidents. Should you have any questions regarding the law or if you are re'quired to obtain a workers'
compensation'policy, please call the Department at the number listed below. Self-iiisur6d companies shpuld'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 perinit/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 01
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
1 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
Final Construction Control Document
To be submitted at completion of construction by a
Registered Design Professional
for work per the 8' edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: FLR 1-3 Talent Retriever Date: 02-03 -2016 Permit No.
Property Address: 50 High Street, N. Andover,
Project: Check (x) one or both as applicable: —New construction X Existing Construction
Project description: Subdivision and renovation of existing office space.
I Donald M. Walte MA Registration Number: 953 6 Expiration date: 8/3 1/2017 , am a registered design professional,
and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning:
X Architectural Structural
Fire Protection Electrical
Mechanical
Other: Describe
for the above named project. 1, or my designee, have performed the necessary professional services and was present at the
construction site on a regular and periodic basis. To the best of my knowledge, information, and belief the work
proceeded in accordance with the requirements of 780 CMR and the design documents approved as part of the building
permit and that I or my designee:
I . Have reviewed, for conformance to this code and the design concept, shop drawings, samples and other submittals
by the contractor in accordance with the requirements of the construction documents.
2. Have performed the duties for registered design professionals in 780 CMR Chapter 17, as apnlicable.
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3. Have been present at intervals appropriate to the stage of construction to become genen , iliar with the
progress and quality of the work and to determine if the work was performed in a manner rn stent with the
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the
Enter in the space to the right a "wet" or
electronic signature and seal:
Phone number: 978 499 2999
Building Official Narne: Permit No.
Version 06112013
Email: dwalter@doreandwhittier.com
Date:
Building Official Use Only
Irl F, V ikm(.�l
VVAZ
H O�
107.
Final Construction Control Document
To be submitted at completion of construction by a
Registered Design Professional
for work per the 8 Ih edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: FLR 1-3 Talent Retriever Date: 02-03-2016 Permit No. -
Property Address: 50 High Street, N. Andover, MA
Project: Check (x) one or both as applicable: —New construction X Existing Construction
Project description: Subdivision and renovation of existing office space.
I Donald M. Walter, MA Registration Number: 9536 Expiration date: 8/31/2017 , am a registered design professional,
and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning:
X Architectural Structural
Fire Protection Electrical
Mechanical
Other: Describe
for the above named project. 1, or my designee, have performed the necessary professional services and was present at the
construction site on a regular and periodic basis. To the best of my knowledge, information, and belief the work
proceeded in accordance with the requirements of 780 CMR and the design documents approved as part of the building
permit and that I or my designee:
I . Have reviewed, for conformance to this code and the design concept, shop drawings, samples and other submittals
by the contractor in accordance with the requirements of the construction documents.
2. Have performed the duties for registered design professionals in 780 CMR Chapter 17, as apr)Lcable.
3. Have been present at intervals appropriate to the stage of construction to become generally iliar with the
progress and quality of the work and to determine if the work was performed in a manner n stent with the
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the
Enter in the space to the right a "wet" or
electronic signature and seal:
Phone number: 978 499 2999
Building Official Name: Permit No.
Version 06112013
Email: dwalter@doreandwhittier.com
Date:
Building Official Use Only
pr MR 107.
ARCH/
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TH O�
Location
No.
Check # -�L41
29979
Date '.2 - --i - i lie
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building�Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL $
Building Inspector
OORIN
ACF
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 700-2016 on 12/8/2015 Date: February 2, 2016
THIS CERTIFIES THAT
THE BUILDING LOCATED, at 50 High Street — Suite 24
MAY BE OCCUPIED AS a tenant fit up — Talent Retriever IN ACCORDANCE WITH
THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH
OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to: RCG LLC
Fee: $100.00
Receipt: 29979
Check : 2-14 11
40
50 High Street
North Andover, MA 01845
I
Building Inspector
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