HomeMy WebLinkAboutMiscellaneous - 34 SAW MILL ROAD 4/30/2018\�
N_
O
o�
A
b
0
0
0
0
0
0
i .�
10009 Date
TOWN OF NORTH ANDOVER
�* PERMIT FOR PLUMBING
This certifies that .. n . ,S... A/A /} '
has permission to perform .... VZ..y!i
l
plumbing in the bJ4.
ildings of. r� „S �/, , , , , , , , ,,,,,, • ...... .
at .....�.. -i, .. �f . , eCy , , ... , North Andover, Mass.
Fee ).. .. Lic. No.,�(' .. / . .................. .. .
PLUMBING INSPECTOR
Check # Lo 3 5-0
DEDICATED EU GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR (INTEL
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
�r�r� � —� �rlil>�[I li'll[
WATER HEATER ALL TYPES
WATER
OTH7R
INSURANCE COVERAGE:
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO E]
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY_! BOND Q
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.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT J
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 i omplianc with all Pertinent grovispn of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME L— wo 1 GecS'/' O LICENSE #
SIGNATURE
MPI JP 0 CORPORATION 0#=PARTNERSHIPD# LLC
e
COMPANY NAME/31�V S PLb; 6"'4 -ADDRESS yw Crrovc Ck y�
CITY � � —_ � STATE iq- (ZIP
TEL
FAX _ ;CELL EMAIL -- l}VL,YBL; rL P1—U'— Wt- a1 �pf
L dot. -
J
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
�
+F�
CITY _ _v
i MA DATE G I �fi_ I PERMIT # 7
JOBSITEADDRESS �`(� �'w��/'
►2r� OWNER'S NAME ri m r -a4
POWNER
ADDRESS
TEL[ kFAX F
TYPE OR
OCCUPANCY TYPE COMMERCIAL E!
EDUCATIONAL D RESIDENTIAL
PRINT
CLEARLY
NEW: RENOVATION: ® REPLACEMENT: 0 PLANS SUBMITTED: YES 0 NOE11'
FIXTURES'l
FLOOR- BSM
1 2
3 4 5 6 7
8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED EU GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR (INTEL
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
�r�r� � —� �rlil>�[I li'll[
WATER HEATER ALL TYPES
WATER
OTH7R
INSURANCE COVERAGE:
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO E]
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY_! BOND Q
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.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT J
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 i omplianc with all Pertinent grovispn of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME L— wo 1 GecS'/' O LICENSE #
SIGNATURE
MPI JP 0 CORPORATION 0#=PARTNERSHIPD# LLC
e
COMPANY NAME/31�V S PLb; 6"'4 -ADDRESS yw Crrovc Ck y�
CITY � � —_ � STATE iq- (ZIP
TEL
FAX _ ;CELL EMAIL -- l}VL,YBL; rL P1—U'— Wt- a1 �pf
L dot. -
J
COD
F
0
H
U
W
a
w
on
z
N
}
O
H
W
v1
O
u
m
_
Z
o
a
L
LLI 5
W
aLLI
W
L
LU
co
a
p
a
w
z
�
a
a
a
a
co
EE
I--
�
w
w
LL
rA
W
H
Z
O
H
U
W
Q,
z
a
a
x
o
0
a
In
The Commonwealth of Massachusetts
Department of IndustrialAccidints
Office of Investigations
UT 600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: f e3o Phone #: — 18 h S
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. [Y I am a sole proprietor or partner-
listed on the attached sheet. t
ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ 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. ❑ New construction
7. E] Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ 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.
$Contractors 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 is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self-iins. Lic:
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 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
Investigations of the DIA for insurance coverage verification.
I do hereby certi nder thepains /and penal iees of/perjury that the information provided above is true and correct.
Signature: /(�(� /�' G�%j�p'7/ Date:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other - -
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,
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 j oint 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 shallnot 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
O
of the affidavit for you to fill out in the event the ffice 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 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 Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston., MA 02111
TeX, # 617-727-4900 ext 406 or 1-877rMASS.AFB
Revised 5-26-05 Fax # 617-727-7749
w.mass,govldza
Date..?/
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that CA'ro-j
........................................................................................................................
has permission to perform ........................ Z/e) ... 1,eos-t ........................................... ..
wirWg in the building of ..... Z. 19-w, oo� I ..... is M
. . ............................... ......
at ........ ........... ... North Andover, Mass.
....... ...... -7-
Fee.'13�5....W:......... Lic. No.-�q�� .
EL cmcAL INSPECTOR
Check #
E
Commoruveahk o f Ma6Aachueeth
2epartment o f Mire Service3
BOARD OF FIRE PREVENTION REGULATIONS
OfficialUseOnly
Permit No. 117.3
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 (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: — x/13
City or Town of: 411111IIIIINNOMM N. ^400' ' To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
!13--l-)
Location (Street & Number)
Owner or Tenant -WY
�Vt�c`1271, i
Telephone No. /-
Owner's Address
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Z" Amps l Ld /2W Volts Overhead ❑ Undgrd � No, of Meters L
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: 411711*AJieM"' 7-j 7W- 644q
Com letion of the followin vtable ma be waived b the Ins ector -f Wires
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
o. of Fotal
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs.,
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ n- M.
rnd. rnd.
o. o Emergency Lighting
Batte Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
o. o Detection an
Initiating Devices
No. of RangesNo.
of Air Cond. Tons
No. off' Alerting Devices
No. of Waste Disposers
eatump
Totals:
.... um er
ons
..................
o. o e - ontamed
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ unicipa Other
Connection
No. of Dryers
No. of Water
Heaters KW
Heating Appliances KW
o. o o. o
Signs Ballasts
ecurity ys'tems:
No. of Devices or Equivalent
Data Wiring:
No. of Devices or E uivalent
No. Hydromassage BathtubsNo.
of Motors Total HP
Telecommunications' trmg:
No. of Devices or E uivalent
OTHER:&,/LL
Rttacn aaattionai detail it desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 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 cover a is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify,:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: ' /?49041 /G' LIC. NO �VJ-4l//�
Licensee: Signatur
LIC. NO.:
(If applicable, a exem t" in the license number line.) Bus. Tel. No. 7� M�/
Address: „�/��/l1. Xi �t/S%/L1/�c5%' Q�f�%3
*Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. Lic, No. 7 /d a
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/Agent El owner's agent.
Signature Telephone No. PERMIT FEE. $ j
}
CITY OF GARDNER, MASSACHUSETTS COMPILATION OF ORDINANCES
NO. 111
AN ORDINANCE ESTABLISHING FEES FOR WIRING PERMITS
Residential Permit Fees
1. New house, less than/equal to 2000 s/f (based on Permit).............................$220.00'
2. New house, greater than 2000 s/f. $220.00 plus $.10 per s/f (rounded to nearest $1.00)
3. Addition/Renovation, less than/equal to 1000 per s/f.......................................100.00
4. Addition, greater than 1000 s/f ....... $100.00 plus $.10 per s/f (rounded to nearest $1.00
5. In -ground pool........................................................................................100.00
6. Aboveground pool...................................................................................50.00
7. Spa/ Hot tub...........................................................................................50.00
8. Service change, first meter.......................................................................65.00
8a. Additional Meter......................................................................................35.00
9. Garage/Barn...............................................................................:........100.00
10. Existing building rewiring (multi -family $95.00 per unit)..................................155.00
11. Temporary service..................................................................................50.00
12. Alarm, Security systems............................................................................50.00
13. Not classified, all other work, minimum fee.....................................................50.00
14. Solar/Wind Turbine..................................................................................65.00
Commercial - Business- Industrial Permit Fees
1. 1 % of electrical construction cost or minimum fee, whichever is greater (proof of
estimate must be submitted with application. Subject to change on condition and
scope of work).
2. Each meter, based on larger disconnect.........................................$0.50 per amp
3. Temporary service/Sign/Gas pump replacement .........................................50.00
4. Phone & Data, 1 % of cost or minimum fee, whichever is greater (proof of estimate must
be submitted with application. Subject to change on condition and scope of work).
5. Blanket permit for industrial maintenance ................................................$250.00
6. Minimum fee.......................................................................................150.00
7. Carnival/Circus/Fair.............................................................................150.00
* Permit fee includes one rough and one finish inspection. $50.00 per inspection for all other
inspections. $50 re -inspection fee will be applied in cases of code deficiency.
Conditions of permit
1. Permit expires one year from date of issue, or if electrical contractor is changed. An
extension may be granted by the Inspector of Wires.
2. Permit fees doubled upon failure to apply for a permit, as required.
Ordinance No. 908 amended by Ordinance Nos. 1036,
1126,1141, 1363, 1414,1449 and 1528
D C -Z7_
ORDINANCE NO. 111 Page 1
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington. Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): (?4Rel) CMS `
Address: J �. 5T0Mi=_-h1/kL.
Phone #:
Are you an employer? Check the appropriate box:
L ❑ I am a employer with
4• ❑ I am a general contractor and I
employees (full and/or part-time),*
have hired the sub -contractors
2.A I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp, insurance
comp. insurance.$
required.]
5. ❑ We are a corporation and its
3. ❑ I aril a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, §1(4), and we have no
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box #1 must also fill nut the sPrtinn 1—In.,, ,i.o:-..,,._,,e-_-
%
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10:® Electrical repairs or additions
11 - Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
Homeowners who submit this affidavit indicating 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 Name:
Policy # or Self -ins. Lic. #:
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 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
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
— .
Phone #:
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,
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 -contractors) 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 i
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/hcense number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. i
The Office of Investigations would hike 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 Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. ## 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 42407 Fax # 617-727-7749
www.mass.gov/dia
Claim #
Advantage Claim Services Adjuster Assigned:
2100.Lakeview Ave.
Dracut, MA 01826
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch.. 139, Sec. 3B
To: Building Commissioner or ✓ Board of Health or
Inspector of Buildings Board of Selectmen
Town Hall address Town Hall
Re: Insured:
Property address:, ") 'S'9W
IV, 4 IVb v V/_" !Q�
Policy #:
Loss of:l�(c//�
File or Claim No. AD yG�
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,_Chapter_143, Section_6 to be applicable. If any
notice under Mass—Gen—Laws,—Ch.-13'9—Sec.-3B is appropriate please
direct it to the attention of the writer and include a reference to the
captioned insured, location, policy number, date of loss and claim or
file number.
Title: Adjuster
On this date, I caused copies of this notice to be sent to the .persons
named at the addresses indicated above by first class mail.
S�-zt4xt
Signature and date
Date ..... .J....'l.t�...� �j.............
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .... .e''.l....... W.cr��,j...........
...........................................
has permission to perform ..i c ..� V1-!. .. z2 ........................................
wiring in the building of....3 . .............................
..........................................
at ......... '—X? .rsl....! �!1..!.�...... �........................... North Andover, Mass.
CFO
Fee... -........... Lic. No. "f
..... ...............ELECTRIC.AL ..................O ...IN .......................
�7
Check* " /� � AL2
C
Commonwealth of Massachusetts �Oficial Use Only4
� �Ib
o
Department of Fire Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank
v
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
a \ All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
` (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date:
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his her intention to performPt ectrical. work described below.
is o
Location (Street & Number) :50 6,,W Y l,,, �
Owner or Tenant Kd
Owner's Address
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service � Amps 12v /210 Volts
New Service Amps .
Number of Feeders and Ampacity
Telephone No.
Yes LTJ No ❑ (Check Appropriate Box)
Utility Authorization No.
Overhead ❑ Undgrd � No. of Meters
Volts Overhead ❑ Undgrd ❑ No. of Meters
Location and Nature of Proposed Electrical Work:
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- ❑
o. of Emergency Lighting
rnd. grnd.
BatteryUnits
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Number
I
I Tons
I *......... "
I KW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total IIP
Telecommunications Wiring:
No. of Devices or E uivalent
[OTHER,
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of li��BEONDEI
nce including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cforce, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE OTHER ❑ (Specify:)
I certify, tinder the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME:. 9 LIC. NO.:35 Off
Licensee: Signatur LTC. NO.:
(If applicable, enter "exempt" in the license numb r 1'ne j. .� Bus. Tel. No.: 7 Z 3— 7—
Address: G' Alt. Tel. No.: hn2=Sfg2
*Per M.G.L c. 47,-`s.-57'- ecuri work requires Departme Public Safety "S' ticense: 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 PERMIT FEE: $
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 'Q
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 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,($:).❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments: .
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INS ION:
Pass
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature: G
G' Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com
r
,ft
The Commonwealth of Massachusetts
Department of IndustrialAccidints
Office of Investigations
600 Washington Street
Boston, MA 02111
VF www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeLyibly
Name (Business/Organization/Individual): N ) 0
u, "C) PIZ,
p• TK in ALN 0381/t
Ci /State/Zi •� ( S(�j �_ Phone #:
Are you an employer? Check the appropriate box:
Type of project (required):
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
6. ❑ New construction
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet.
E] Remodeling
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.
g, ❑ Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
10.❑Electrical repairs or additions
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
11. [_1 Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12. ❑ Roof repairs
insurance required.] f
employees. [No workers'
13. ❑ Other
comp. insurance required.]
*Any applicant that checks box 41 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.
#Contractors 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 is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:,
Policy # or Self -ins. Lie.
Job Site Address:
Expiration Date:
City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder 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
Investigations of the DIA for insurance coverage verification.
Ido hereby cert' under the pains and penalties of perjury that the information provided above is true and correct.
Si atur . Date: l
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
r p
't
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 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 loeal 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 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 Massachusetts
Department of Industrial Accidents
Office ofIavestigat>ions
600 Washington Street
Boston, MA 02111
Tel, # 617-727-4900 ext 406 or 1-877,7MASSAFB
Revised 5-26-05 Fax # 617-727-7749
www.Mass,gov/dia.
f
,�
f
r