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HomeMy WebLinkAboutMiscellaneous - 37 FAULKNER ROAD 4/30/2018 (2)N J V a' c r O Z ; N m O � O O O v O Location No. ' Date Of NORTH TOWN OF NORTH ANDOVER '5009 Certificate of Occupancy $ o ; ; Building/Frame Permit Fee $ ,ssAGMUSEt� Foundation Permit Fee $ R Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector Div. Public Works I.0 CD 0 0 0 0 o ::r.__ -I '0 0 `< m C v = m D O v 'a(1) N rn (D 0 o 0 C,j m s (D0 ° -n cn 3, rn � o N N 0c rn D 14 o C (D cn = (n ? 0 � 0 s � � � • c CD c v r6 0 � cn z n Z 0 Z o 0 \ N O -9 TO 27 U) O (D O C 2 Ln '` ♦� ti (D Q tet' -i Z s► ��SJ:. .�-' Off' \\� (D -0 C -0 .(D 1 m o Fo - 0 Z O v U o o_ (D y _ CD s O cn < CL N m CL �- c r = h cD Z c c - z G) m m z (D v (D 0 D cD 0 0 O Q (D. 27 U) n CD V 0 O N (D n 0 0 0. 0 O- w 3 si% �• cD v o c cr X Z O O 0• 00 v a v (OCD (D Q. 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Q L N (D O 0 0 U) (D COL I (II im 0 v ^YI Y J zz u m M TD V r D z O5 z O m z D z O m X W 0 Z 2 Z LL0 0 J API (PLEASE By this apj Location I Owner or Owner's) Is this per Purpose o Existing S Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 1R� � � —' Occupancy and Fee Checked [Rev. 1/071 (leave blank 'LICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 PRINT ININK OR TYPE ALL INFORMATION) Date: 01- V6- I S ity or Town of. NORTH ANDOVER To the Inspector of Wires: plication the undersigned gives notice of his or her intention to perform the electrical work described below. Street &Number) 31 1-A„kk nem (24- (2 vZ Tenant Yy$%*r I -C - in Cv. 4r� Telephone No. 911$ - (o'b2. - S y 1� .it in conjunction with a building permit? Yes ❑ No © (Check Appropriate Box) Building 4 nnnf_ Utility Authorization No.�4 7 20 f J 3 _Lc:� Amps 12AI, / Lit Volts _A-. Amps lyu Volts Number oFeeders and Ampacity Location a d Nature of Proposed Electrical Work: Overhead ® Undgrd ❑ Overhead 9 Undgrd ❑ No. of Meters No. of Meters Completion of the. following table may be waived by the Inspector 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. o Emergency Lighting rnd. rnd. Batter Units No. of Rec ptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones 1No. of Swi cines No. of Gas Burners No. of Detection and Initiating Devices No. of Ran Yes No. of Air Cond. Total Tons No. of Alerting Devices No. of Wa a Dis Heat Pump Number Tons I.KW _ No. of Self -Contained posers p Totals: Detection/Alerting Devices No. of Dist washers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No, of Dry rs Heating Appliances KW Security Systems- No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: He aters Signs Ballasts No. of Devices or Equivalent No. Hydror iassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wres. Estimated Vz lue of Electrical Work: 2 k 2 cso (When required by municipal policy.) Work to Star: Ct - 2 % -1 !� Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANC 9 COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee p rovides 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 O : INSURANCE W BOND ❑ OTHER ❑ (Specify:) I certify, untl r the aims a. dpenalties ofperjury, that the information on this application is true anti complete. FIRM N • c, 1 te+r� �xJ t LIC. NO.: A l �{ Z Licensee: ��,���. t _ Signature LIC. NO.: SS4 2 (If applicable, ter ` mpt" in;he license number line.)(('� Bus. Tel. No.: p L' Address: �c.c c .� t J �,t-� W b 22 Alt. Tel. No.: 3- 233— 14 %t i *Per M.G.L d 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S 11 iSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by la Y. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agen 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 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 F?1 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 M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass IN Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com i/ Name Address: Are you an emplo 1.❑ I am a emplo 2.Q I am a sole pr any capacity. 3. ❑ lam a homeo 4.❑ I am ahomeov ensure that all proprietors wit 5. ❑ I am a general These sub -con 6.O we are a cc 152, §1(4), *Any applicant that i Homeowners who $Contractors that eb emnlovees. If the si I am an employer information. Insurance Compai The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA. 02114-2017 www mass.gov/dia Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING ,A.7JTHORR Y. -- , Phone #: heck the appropriate box: with employees (full and/or part-time).`4 ietor or partnership and have no employees working for me, in oworkers' comp. insurance required.] er doing all work myself [No workers' comp. insurance required.] t er and will be hiring contractors to conduct all work on my property. I will intractors either have workers' compensation insurance or are sole no employees. and I have hired the sub -contractors listed on the attached sheet. ve einpioyees and have workers' comp. insurance.# I its. officers have exercised their right of exemption per MGL c. no employees: [No workers' comp. insurance required.] Type of project (required); 7. [] NeW'd6ns"&1on 8. Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12. []Plumbing repairs or additions 13%[) Roof repairs 14.0 Other bb9r#i must also fill out the section below showing their workers' compensation policy information: this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such box must attached an additional sheet showing the name of the sub contractors and statg whether or not those entities have ractors have employees, they must provide their workers' comp. policy number. rt is providing workers' compensation insurancefor my employees. Below is the policy and job site Policy # or Self -ins} Lie. Expiration Date:. City/State/Zip: Job Site Address: Attach a copy of a workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure co erage as required under MGL e. 152, §25A is a criminal violation punishable by a tine up to $1,500-00 and/or one-year im risonment, 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 viol tor. A copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance Ido hereby certify nder the pains andpenalties of perjury that the information provided above is true ana corrc mature: one #: 7]B30 only. Do not write in this area, to be completed by city or town off Bial. wn• Permit/License # thori (circle one): f 11 2. Building Department3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Person• Phone #: Ij 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 ofthe 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 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 uotproduced-acceptable evidence of compliance with the insurance coverage required. Additionally, MOL chapter 152, §25C(1) 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 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 IndustrialAccidents. 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 "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: 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 # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia A DATE: 9 -1 �- )15 - LOCATION:. 3 7 14-.- OWNEIIS NAME: Mk - GENER4TOR kw ICP 'p� NO INS CONTRA R: 1p PHONE NUMBER: toot , G.t 2 - ELECTRICAL RESIDEN LOCATION "'ZONING gas COMMERCIAL 10 TEMPORARY F GENERATOR: j� STRICT: "'PLANNING PPROVAL (IF IN WATERSHED) "'CONSERVA ION APPROVALoij LA, North Ander MIMAP 01 0 d F�Q��-41 .,� o-7.. �:_ � r �a �1�'asp,• � � s s r: Parker Street 0 MVPC Bo Interstates — I i — SR Roads Ce Easements D Parcels j September 16, 2015 �. jI NN f WY 3 G q . . ,7" "� '" k,<... .sus •wr° r A -C } Y $ - 7 A r )v� 1"=39ft Oil o��e. Horizontal Datum: MA Slateplane Coordinate System, Datum NAD83, Meters Data Sources: The data for this map was produced by Merrimack NORTH Valley Planning Commission (MVPC) using data provided by the Town of Or ,ao , q .S CQ North Andover. Additional data provided by the Executive Office of Environmental Affairs/MassGIS. The information depicted on this is .ZF b* L% G ''' in map for planning purposes only. It may not be adequate for legal boundary •"- ' definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT �► o'q ,. i ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION 1"=39ft Oil o��e. 1 J Liberty Mutual. INSURANCE 2015 Town of North Andover Attn: B ' ding Inspector 120 M4 Street North A dower, MA 01845 Liberty Mutual Insurance New England Region Central Property Unit 75 Sylvan Street Danvers, MA 01923 Tel: (800)566-0323 Re: P operty Address: 37 Faulkner Rd, North Andover, Ma 01845 P licy Number: H3221817661801 U derwriting Company: Liberty Mutual Fire Insurance Company C im Number: 032249440-0001 D to of Loss: 6/16/2015 Attn: Ton/City Official Pursuant t M.G.L. c. 139, § 3B, please be aware that a homeowners insurance claim has been made involving 1 ss, damage or destruction of the above captioned property, which may either exceed $1,000.00o causes the condition of a building or other structure to render Mass. General Laws, Ch. 143, § 6 ap licable. You are required to notif T Liberty Mutual by certified mail in accordance with Mass. Gene al Laws Ch. 175, §99, if you intend to initiate proceedings designed to perfect alien pursuant to Mass. General Laws, Ch. 139, § 3A & B, or Mass. General Laws, Ch. 143, § 9, or Mass. General La s, Ch. 111, § 127B. This letters ould not be construed as a waiver or estoppel of any of the terms, conditions or defenses affded by the policy or applicable law. Please direct our notice to the attention of the undersigned and include a reference to the above captioned property address, policy number, claim number, and date of loss. Sincerely, Liberty MutuSupport Liberty Mutual Insurance New England egion Central Property Unit 1-800-566-032 Liberty Mutual. INSURANCE Januar 24, 2013 Town o North Andover Attn: BjAdover, ding Inspector 120 MStreet North MA 01845 Liberty Mutual Insurance New England Region Central Property Unit 75 Sylvan Street Danvers, MA 01923 Tel: (800)566-0323 Re: Piaj° perry Address: 37 Faulkner Rd, North Andover, MA 01845 Pd 'cy Number: H3221817661801 U derwriting Company: Liberty Mutual Fire Insurance Company Cl ' Number: 024544793-0001 Da a of Loss: 10/30/2012 Attn: TownVCity Official Pursuant toG.L. c. 139, 5 3B, please be aware that a homeowners insurance claim has been made involving los , damage or destruction of the above captioned property, which may either exceed $1,000.00 or auses the condition of a building or other structure to render Mass. General Laws, Ch. 143, 5 6 app able. You are required to notify Liberty Mutual by certified mail in accordance with Mass. Gener Laws Ch. 175, 599, if you intend to initiate proceedings designed to perfect alien pursuant to ass. General Laws, Ch. 139, � 3A & B, or Mass. General Laws, Ch. 143, � 9, or Mass. General Laws, h. 111, 5 127B. This letter sho d not be construed as a waiver or estoppel of any of the terms, conditions or defenses afford d by the policy or applicable law. Please direct yonotice to the attention of the undersigned and include a reference to the above captioned prope ty address, policy number, claim number, and date of loss. Sincerely, Kristen Hart Liberty Mutual In urance New England Re on Central Property Unit 1-800-566-0323 E t. 70417 E-mail: Kristen.H rtl.LibertvMuhial.c-�m