HomeMy WebLinkAboutMiscellaneous - 355 WOOD LANE 4/30/2018 (2),. j
Date ....,1..
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
CHU
This certifies that .............A 4--IISA-Aj
..........................................................................................................................
. ..... ...... ... . ........... .....
has pen-nission to perform ...... g . ...................
f
wiring in the building o .. . ..............................................
at 3.1.3s .......... W.,D.,j ..... L.A,, Q— o A,
......... .... .... ..... . ..... ........ �dover, Mass.
Fee... . 7 .......... Lic. No.3%
..... ................. ...... .. (,.. .....
ELECTRICAL INSPECTOR
Check #
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commonwealth of Massachusetts Olcial Use Only
..
Department of Fire Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07]
(leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00
(PLEASE TAWT MINK OR TYPEALL INFORMATION) Date: 7-/4-/-/5_
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) 3 SS lvDo 4,3u t
Owner or Tenant 119A-) C n n ,'-. Y lytt� Telephone No.
Owner's Address 3 SS c,,o-a b L- � �k
Is this permit in conjunction with a building permit? `Yes ❑ No ❑ (Check A propriateeBoox) -_-
Purpose of Building 'n9l - ,Utility_ Author zation No. _ ,, 1 0
Existing Service /cam Amps t u; 12 yG Volts Overhead. Undgrd ❑ No. of Meters /
New Service Zoa Amps ) 06 / 2 y 0 Volts Overhead 5�, Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed EIectrical Work: A"SwV&"'( F vQ6-jz b�
1\
Completion ofthe 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- Ll
rnd. rnd.
o Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No, of Zones
No. of Switches
No. of Gas Burgers
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
Tons
KW
.......................
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
p g
Local ❑ Municipal ❑ 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:
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: 7—/_5--/5- 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 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 ❑ BOND ❑ OTHER ❑ (Specify:)
I" certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: P sS e // 7- Iis � .116 _ LIC. NO.: 3<,-- 3�/ zr-
Licensee: d vs5e/f S • TZmAS5.h kJ ign LIC. NO.:
(If applicable, enter "exempt" in the license number line.) Bus. Tel. No.Q Vis`^
Address: �o� n-c2n ,.•+,;c/zcr�ii-c��- t 111 Alt. Tel. No.•
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
�
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
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 r
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 [d
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INECTION:
Pass
Failed '❑
Re- Inspection Required ($.) ❑
Inspectors Comments:
444
Inspectors Signature:
Date: -7
PARTIAL ROUGH INSPECTION:
Pass IN
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 INSPECTION:
Pass 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com
P
The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Buffdexs/Contractors/Electricians/l'lumbers.
TO BE FILED WITH THE PERMITT)NG AUMORIT Y.
Annlicant Information Please Print Legibly
Name (Business/Oigavization/Individ,,d): t2JSS z j t S c-' SS 1" Y�
Address: /w P k 0- "z; -�
City0ate/Zip:_
vT
Are you an employer? Chec$the appropriate box:
I --oz, 7S Phone #: '16 — SQnof - _��V
1.Q I am a employer with employees (full and/or part-time).','
n a sole proprietor or partnership and have no employees working forme 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 contractprIand I have hired the sub -contractors listed on the attached sheet.
These sub -contractors Irave employees and have workers' comp. insurance.#
6.Q We are a corporation and its, officers have exercised their right of exemption per MGL c.
152, §1(4), and'we Have no empldyees. [No workers' comp. insurance required.]
Type ofproject (fequired):
7. ❑ N6*'d6nstrd'ct1on
8. [] Remodeling
9. ❑ Demolition
10 Building addition
11.0 Electrical repairs or additions
12.[] Ptumbing repairs or additions
13•.[] Roofrepairs
14. [] Other
,Any applicant that checks box 41 mrist also fill out the section below showing their workers' compensation policy information.
Homeowners who submiitbis affidavit indicating they are doing all work andthen hire outside contractors must submit a new affidavit indicating such
tContractors that check this box must attached an additional sheet showing the name of flee sub -contractors and state whether or not those entities, have
employees. Ifthe sub-contraetois have employees, they must provide their workers' comp. policy number.
X 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. LIC.
Expiration Date:
lob Site Address: City/State/Zip:
Attach a copy of the workers' compepsation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL e. 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 andpenalties ofperjury that the in
provided above is true and correct.
- -�— - Date:
?-r -SCo 9- `33oS
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): i
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other -
Contact Person:
Phone #:
• The Commonwealth of Massachusetts
Department of IndustrialA.CCidents
I Congress Street, Suite 100
Boston, MA. 02114-2017
9t www mass.gov/dia
oM SV�V
• Workers' Compensation Insurance Affidavit: Builders(Conixactors/Electricians/Plumbers.
TO BE FILED WITH THE PFIRMMtgG AUTHORTTY. -• Please Print Le 'bl
A '' licant Infoxnaation
Name (Business/Organization/Individual): I2.SSS 2 1 ( Ic yr t SS r.a
Address: /crG , vici i4v -I—
City/State/Zip:_
Are you an employer?
.,+ N. 1"A , 11-fo
clktbe appropriate box:
2
Phone 4:
1.Q I am a employer with employees (full and/or part-time).
n 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 al work on my property. I will
l
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. ❑I am a general contractor and 1 have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance �
6. ❑ We are a corporation and its, officers have exercised their right of exemption per MGL c.
152 § 1(4), and we kiave no employees. [No workers' comp. insurance required.]
Type of project (required):
7. ❑ Ne do` ns"d`tion
8. �] Remodeling
9. ❑ Demolition
10 [] Building addition
11.❑ Electrical repairs or additions
12,; U plumbing repairs or additions
13.0 Roof repairs
14PI Other.
*Aary applicant that checks box #i mtist also then hire outside contractors must submit a new a
fill out the section below showing theirworkers' compensaflon po"oy information.
Homeowners who submit•tox affidavit indicating They are doing all work and of the sub -contractors and state whether or not (hose enti
affidavit indicating such.
(Contractors that checkthis box must attached an additional sheet showing the name ties have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
compensation insurance for my employees. Below is the policy and job site
jam an employer that is providingyvorkers'
information.
Insurance Company Name'
Policy # or Self -ins. Lie. ih .
Expiration Date_
City/State/Zip-
lob Site Address:
compensation policy declaration page (showing the pokey number and expiration date).
Attach a copy of the workers'
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 under thepains andpenalties ofperjury that the information provided above is true and. correct.
Date
Phone #:
Official use only. Do not write in this area, to he completed by city or town offieial
City or Town:
permit/License
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 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
receivef6r, trustdd 6fan 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 occup_ant 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
Pleasb 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 certificates) 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
thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "lob Site Address" the applicant should write •"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 isle 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-MA.SSAFE
Fax 4 617-•727-7749
Revised 02-23-15 wwwmass.gov/dia
A. COMMONWEALTH OF MASSACHUSETTS
0 0 0
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_
6(3AFiD OF
ELECT'R I C I ANS
f
ISSUES
THE FOLLOWING LICENSE,
AS A' REG
'JOURNEYMAN -,ELECTRICIAN:
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RUSSELL J TOMASS I AN `r✓
1'
'
W
104 DRAPE RD
tii
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t ,I
12
BURL I NG ....K
1+tA 01803-1835
38361; E
0713,1;/16 32501
.,
MASSACH'JSETTS UNIFORM APPLICATION FOR. PERMIT TO DO GASFITTIN(3
(Print or Type) _
C NORTH ANDOVER �^ Mass. Date oZ rj
Buildina Location J � LAzon` 4- �, Permit 2
.� Owners Name 2
New ^ Renovation D Replacement jfK Plans Submitted D
s FIXT(c
(Print or Type)n,,�� (QJ r ( Check one: Certificate
Installing Company Name Cai�CJ� � ("C Q Corp.
Address SIT Partner.
N. tom" Firm/Co.
Business Telephone: & 0 I
Name of Licensed Plumber or Gas Fitter
Insurance Coverage: Indicate the type of i:-isurance coverage by checking the
appropriate box:
Liability insurance policy [W] Other
Insurance Waiver: I, the undersigned
this application does not have any one
Signature of owner/agent of property
type of indemnity Q Bond 0
have been made aware that the licensee of
of the above three insurance coverages.
Owner 17 Agent El
I
I hcscby 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 ill plumbing work and Installations performed under Permit iuLed for this application will -be in compliance with aL pertlnent
prorisions of the Massachusetts State Gas Cade and tlapter 14I of the Genual LAWS.
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICENSE:
Plumber
Ga sf itter
Master
Journeyman
S'g ature of Licensed
P1 �b�eoGasfitter
License Number
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(Print or Type)n,,�� (QJ r ( Check one: Certificate
Installing Company Name Cai�CJ� � ("C Q Corp.
Address SIT Partner.
N. tom" Firm/Co.
Business Telephone: & 0 I
Name of Licensed Plumber or Gas Fitter
Insurance Coverage: Indicate the type of i:-isurance coverage by checking the
appropriate box:
Liability insurance policy [W] Other
Insurance Waiver: I, the undersigned
this application does not have any one
Signature of owner/agent of property
type of indemnity Q Bond 0
have been made aware that the licensee of
of the above three insurance coverages.
Owner 17 Agent El
I
I hcscby 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 ill plumbing work and Installations performed under Permit iuLed for this application will -be in compliance with aL pertlnent
prorisions of the Massachusetts State Gas Cade and tlapter 14I of the Genual LAWS.
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICENSE:
Plumber
Ga sf itter
Master
Journeyman
S'g ature of Licensed
P1 �b�eoGasfitter
License Number
TJO 1582
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pF ,,Eo ,^1ti0
40
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�9SSA USEtS�
Date.! ./J./.—. .si.....
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .. 1,.19./71). o.� .�.....��..��............
has permission for gas installation .. C { :... ................
in'the buildings of-` .1./1 .........................
at .. .. iti .. ............ North Andover, Mass,
Fee. 1Y. X25%94 0 z ?. ..........................
9.35 15.00 PADS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
Location f -
No. G Z 7 Date�-
OF NORTH ANDOVER
of Occupancy $
rame Permit Fee $
n Permit Fee $
nit Fee
inection Fee
nection Fee $
Building Inspector
Div. Public Works
X:
Location 4//p
No. / Date ��� 7/12
TOWN OF NORTH ANDOVER
'A' cp Certificate of Occupancy $
�o }' Building/Frame Permit Fee $
<�! t Foundation Permit Fee $
°ermit Fee
JQ+Y 2 �Sewer Connection Fee $
'Q�
+Y ��d4later Connection Fee I
Na. Anaover GollQ6r L
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,�le Building Inspector
Div. Public Works �
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GLGRGE 1IURLM" DBA
The Construction I?lchange
240 Lafayette Rd.
tt Seabrook, NH. 03874
Custoi;ur . ThAnny 7_appala Date : CTOY 94
355 Wood Ln.
.Io..lnclover, Ma.
Subieet : KitJicii remodel.
1 1-e1uuvc existing walls and install two 8" x 10" fir support beams.
2) Insulate e%tcrior kitchen v all, frame and install a weather shield casement window.
3) Listall �heetrock, mud, tape, sand and prime.
4) 5anc1 paint kitchen and dining room ceiling.
51 Install 400 sq. ft, hard« ood oak flooring with four coats of polyurethane, Sand
till ng r0ow floor and put on four coats of polvurethanc.
6) Listall cabinets and formica backsplash supplied by Timber Mart.
7) Install interior trim and hang three 6 panel pine doors.
s) 'This quote has an allowance of 51400.00 for electric, outlets, switches both rooms
to cocle.
9) i his ccmlract has an option of installing the casement window with eliptical top or
hiailcling otnt the lJOIcrn window and rooting it.
1Tn,,W11 cnstome made counter top �Nitln oak edge; customer to pick out laminate.
11 )This contract covers all labor. additional materials, window and rubbish removal.
Customer responsible 10 - all painting and staining.
Total labor and materials: $12,745.00
:liiy unforscen damage «-ill be Drought to the customers attention with options and
pnce 10 T'Cpllr.
YaNmcm scfludule:
r
r i avrnrnt Atte at start S6500.00
Fa: i cni duc .it stall of I'loorino 53000.00
I'tj Payl11Cnl Niue upon compiztioll S745.00
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Customer
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