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HomeMy WebLinkAboutMiscellaneous - 328 MAIN STREET 4/30/2018N O_p A N W c° O � y Z W m , 0 I TOWN OF NORTH ANDOVER PERMIT FOR WIRING ® �� e This certifies that .... ....lJ/�.�i. �./ ......................................................................................... has permission to perform ............ :. /1 J ^..G / ............................................... wiring in the building of.......�Q..!„! ,l!� �-� ............................................................................... at.....�.G.......................=`:......................................................, Andover, Mass. Ae J ............... Lic. NA.7........ ............................................................. ELECTRICAL INSPECTOR Oheck # S � /% Al y ii C mmonwealth of Massachusetts Ilk �1 = Department of Fire Services 0 a BOARD OF FIRE PREVENTION REGULATIONS f t Official Use Only Permit No. r Occupancy and Fee Checked :ev.1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (ME ), 527 C 12.00 (PLEASE PRINT W INK OR TYPE ALL MFORMATI0119 Date: /Q3-OL/S-- City 3-a 1SCity or Town of: NORTH ANDOVER To the Inspector ofMires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 3R f A4 W Owner or Tenant Owner's Address Telephone Nol Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: X % v fig PyZYA Com; e47` kt4L /te IILUV q>" t7b 9 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 ❑ In- ❑ rnd. grnd. No. of Emergency Lighting Batteg Units No. of Receptacle Outlets a No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and InitiatinLyDevices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Dis osers p eat Pump Totals: Number Tons KW .......... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Spac Area Heating KW Local ❑ Municipal F1 Other Connection No, of Dryers Heating Appliances KW Security De icl s 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 evices Equivalent CA--] OTHER: X Attach additional detail if desired, or as required by the Inspector of Wires. l*stimated Value of Electrical Work: Jj 0Zr0 (When required by municipal policy.) Work to Start: /S Inspections to be requested in accordance with NEC 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 K BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties f perjury, that the information on this application is true and complete. FIRM NAME: .r LL � LIC. NO.: 7 � fAW l Z Licensee: rryj Signature LTC. NO.: J�((o.3 (If applicable, enter "ex pt" in the li nse number lin .) !! ,, !� Bus. Tel. No. -.6n j-Ak0 `6y �y Address: PD I PCt� q G�SIrO �ff ® 310 3 Alt. Tel. No.:lna3 -L� 0�%7 �?o *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) ❑ owner ❑ owner's agent. Owner/Agent 1�1' Signature Telephone No. PERMIT FEE: $ h� .i r ❑ 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 F electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the 1 notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending -through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: T Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ R Inspe ors Comments: 24 Inspectors Signature: Date: FINAL INSPE ON: Pass Failed Re- Inspection Required ($:) 0 Inspectors Comments: 45 Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com J The Commonwealth of Massachusetts Department of Industrial Accidents d 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): �Yl -r, r, «c Address:/ aczq a C. 3 (C"t w_�- Ly City/State/Zip: Phone #: 1) 3 &3.4 -79_20 Are you an employer? Check the appropriate box: 10 1.�I am a employer with 16 rup oyees (full and/or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.❑ 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. ❑ 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.t j 6. ❑ We are a corporation and its officers have exercised their right of exemption 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. gDemolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other that checks box #I must so fill out the ion below showing their workers' compensation policy t Homeowners who submit this affidavitalindicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors 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. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lie. 9. /J K S Expiration Date: c Job Site Address: 3 ? © City/State/Zip: 041 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 cov, rage verification. -11% Idohereby-5ed,y' un r th ains a �ialties of perjury that the information provided above is true and correct f Signature. Dnte- Phone #: 603- 00,6 6 _60V 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 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 of hire, i express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has 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 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 should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: Revised 02-23-15 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 www.mass.gov/dia September 9, 2014 THEW OP8IfO0.06eD1EDC-0AflbIGROUPo FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B Building Commissioner, or Inspector of Buildings C/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1479512 Insured: EUGENE A BELIVEAU Address: 328 MAIN ST, NORTH ANDOVER, MA Policy No.: F0118492 Loss Date: 09/06/2014 Loss Type: Building or Other Structure Damage A claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 313 is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, Michelle M. Roust Senior Property Claims Examiner 1-800-688-1825 x1171 NORFOLK & DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street, P.O. Box 9109, Dedham, MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO. Telephone: (800) 688-1825 FITCHBURG MUTUAL INSURANCE CO. 0 Fax: (781) 329-1818 Date. J-)/O/(� TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION This certifies that .... �..A ............... has permission for gas installation C. 1r.". (` ......... in the buildings of el X .................. at 3 ci............ North Andover, Mass. Fee. A Lic. No. .. .... 6AS INSPECTOR Check # 12 -? 7 6860 4. In MASSACHusurS UNiFoRMAPPUCATONFOR PERM TODOGAS FlT MG (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Loqationsg �'', 9 .` n ' ,s f' / Permit # tD � Amount W x Plans Submitted Owner's Name New rM Renovation Replacement ❑ w ' rA c� m a o ° . w rnF w a p o c zrnG. �'z v w w F a a w Q Z 5. W �.. Z F a UDz' o z w w ID SUB -BASEM ENT BASEMENT 1ST. FLOG R D. FLOOR 3R D, FLOOR ATH. FLOOR TH. FLOOR 6TH. FLOOR 7TH. FLOOR. BTH. FLOOR. (Print or type) Name �CSS AW Sy' Zk Cneck one: Certificate Installing Company �' / cA � p�( � Corp. Address e� g l/ Gcd I— Y— S rd o v o S 0/ i Partner.3usmess Telep one %J8r ys Finn/Co. Name of.Licensed Plumber'or Gas Fitter _Z/1 -t S -,VR 1-Pv v 5e J'1' INSURANCE COVERAGE I have current liability insurance, policy or it's substantial equivalent. Check one: If you have checkedyes, please indicate the type coverage by checkin the Yes Liability insurance policy ® Other f: d g appropriate box, No13 type o rn emnity Q Bond Owner's Insurance Waiver 1 am aware that the licensee does not_ h_� the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner 0 1 hereby certify that all of the details and information I have submitted (or entered) in pplincationare true and accurate to best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will e in the compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter .142 of the General Laws. By: Title Zity/Town. IAPPRO VED (OFFICE USE ONLY? ®Signature of Licensed Plumber Or Gas Fitter - Plumber A,S,te✓ >/&9 Gas Fitter License 1 um er ` L 9 & ® Master 0 Journeyman i i;kiµ u uu J _ __......w.�wCCLLttI of Massnchusettc• Department of jndt1-1t1, o11Accide)jic Office of fnvestie ations 600 N'ashineaton. Street L'ostosl, M14 62111 Workers, Colmpeasation Insurance wK rnQsSgov/dia Ri Aca.nt Information ciavilt: Euijders/Contractors/Eiectriciaas/piwn -- Viers Name (Business/(Drganizadon/individual): Address: Q/ 41 C"yistate/zip:� yn s s a 5 Phone #: Are you an employer? Check the appropriate box: 1.2-1 am a em Io -� ,mss dC p .7 with O 4. ❑ I am a tro employees (full and/or * a..r�eral contractor and l 2. ❑ I am a sole r per -time). have hired the sub - t' -H, it or partner- ship and have no employees working for me in any capacity. NO workers' comp. insurance required_] 3 • ❑ 1 an a homeowner doing all work myself. NOworkers' comp, insurance required] t listed contractors ° the attached sheet x These stela -contractors have ❑ workers' comp. insurance.. S. We are a corporation and its officers have exercised.their right of exemption per MGL c. 152, g 1. (4), and we have no employees. [No workers, Tyles of project .(required 'b. ❑ 1\ew construction 7• ❑ Remodeling . 8. ❑ Demolition 9. ❑ Building addifim ] 0:❑. E}ectrical repairs or additions I l Plumbing repairs or additions �2=❑ Roof repairs *Ant! appiicant_thm Checks box # I .most also fill out the section below tahoinSUMnCe required]' 13.(] Qt}1er 1M, omnownerg who submit.tltis ar—jdavn indicarin� "'rng their work' 7Contracrors that eheci; this box.musf ` �`� arc ""in=' c{c:.•i a<i�` Compensation policy, information. attached an addirional sheet showi �' hire °utsiae aon tors rnu4t su' . the name of the sirh ccatractars and to Writ a new aniciavit indicating--tch. I am an . de3re,� the a provi&nv work ' „ air workers' MMP, ififormadom c �^S �iJFltPePrSa�ioEZ E�YSifFanCe fOl ' P PoiiC)' information. � emPLOYCM Below, ' L Insurance Company Name: a ✓ /-;o cPnhc3' andjob site Policy # or Self -.ins. Job Site Address: 3 1 S Expirafion Date: Attach s Copy of the workers' compe.Rsation poiicy decla city/Stat zip' Failure to secure coverage as required under Section 25A Of -MGL lobe (showiag the oft fine up to 31,500.00 and/or one-year imprisonment policy number and expiration date! prisanment. as well MGL c. 152 can lead to the imposition of Of up to .S2S0.00 a day against the violator. Be advised that a coivil penalties in the form of a STGP WORkmOal penalties of a investigations of the DIA for insurance coverage verification py of this stat RDER and a fine emenf may be forwarded to the 'Office of I do hercbT ccT fy under the palm, and penalties �o e 'u iP r3 that the informafiorr provided above rs t Sisr►ature: and correct Phone #: % fr , Date: g _ S - O g Uncial use nndp. Do nnl write in this area, to be eomP[eted h3' citjr or tnw n nf,j L City or Town: Issunar, Authority (circie one): Permit/License ;r 1. Board of Health 2. Buiidictg Department 3. City/Toh.° Clerk 4. Electrical 6. Other tried inspector S. PiumbiRQ Inspector Contact Person: Phone #r Massachusetts General.Laws chapter 152 requires all employers to provide workers' compematior for their employees. Pursuant to this statute, an employee is defined. as ".. every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and inciuriirtg the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, associate on or other legal entity, employing employees. However the owner of a dwelling house having not more than .three ap, - rtments and who resides therein, or the occupant of the dwelling house of another who employs persons to dD maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be d^emed to bean employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuanceor renewal of a ficense or permit to operate a bnsiness orr- to constrvet hufidineus in the commonwealth for Roy applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Netther -the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public worl< 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 comp-etely, by checking the boxes that apply toyour situation. and, if necessary, supply sub-cbntra.ctor(s) name(s), address(es) am d. phone nwmber(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limite6 Liability Partnerships (LLP) with no employees other than the members or. partners, are not required to cairy..workers' compensation insurance. ff an LLC or LLP does have employees, a policy is required. Be advised that this.afficlavit may submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the. affidavit. Theaffidavitshould be returned to the city or gown that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have art} questions rer*ai-rdirg the •iaw or if you are mquired to obtain a workers' .compensation policy, please call the Department at the namniacr:list.ed below. Self insurcd companies should enter their self- nsurance licm- se number on the appropriate line. City or Town Officials Please be sure that ti e-kffidavit -is complete and printed legibly. The Department has provided a space at the bottom of the affidavit foryou to rill out in theevent the Office of Investigations has to contact you regarding the appli=L Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that most submit multiple p=iMiconse applications m arty 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 srn aped or marked by the city or town may be provided to the applicant as proof that a valid affidavit isl on file for future permits or licenses. A new affidavit must be filled out each year. Whom a home owner or citi7--n is obtaining a licems or permit not related to any business or commercial venture (i.e. a. dog license or permit to bornleaves 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 fay, number. The Commonwes;ltb of Massachusetts I3epar. finent of Imidustrial Acca d :fits. Office of Lnvestigatiotns 600 lWashidrigton Street Boston, MA 02111 Te1. 4 617-727-4900 art 406 or 1-877 MASSAFE Revised 5-2645 Fay, * 617-72.7-7749 www1 mass.gov/dia