The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 37 FERNVIEW AVENUE 4/30/2018I Date...' TOWN OF NORTH ANDOVERp PERMIT FOR WIRING This certifies that ....e (j,(, �j� � G� ..................... .................... ......................... has permission to perform ........�K ...S ...................... wiring in the building of ............/. HT1- ................................................. at .... 7. F !1 . � E .. v ... .... ,North Andover, Mass. N �.rJ... Fee.... Lic. No..7G. ...................... 2!.--... ss 1/63 ELECTRICAL INSPEC ,64 Check # �Q 89U6 x Commonwealth of Massachusetts Official Use Only Permit No. slc a Department of Fire Services 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 (M C), 527 CMR 12.00 (PLEASE PRINT OR TYPE A L INFORMATION) Date: q City o Town f: �64& PP Awe To the Inspect6r of ices: By this applicatio dersigned gives no e of his or her intention to perform the electrical work described below. Location (Street & Number) F -"O V1 &V Iq U� Owner or Tenant Telephone N . Owner's Address No. of Waste Disposers Is this permit in conjunction with a building permit? Yes ❑ No x BLDG PERMIT # 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: Install low voltage security system at above location 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 -No. 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 Burners No. of Detection and initiating llPvirPc No. of Ranges No. of Air Cond. Total Tons No. of Alerting g No. of Waste Disposers Heat PumpNumber Tons "" KW .......... No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers y No. of Dryers No, of Water Heaters Space/Area Heating KW Heating Appliances KW No. of No. Hydromassage Bathtubs INo. of Motors OTHER: W, Ballasts Total HP Local ❑ run No. of evices or No. oTD—e7MM ecommunications No. of Devices or Other lent Attach additional detail if desired, or as required by the Inspector of N"fres. 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 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: Brinks Home Security LIC. NO.: Licensee: John Holmes Signature �,� �� LIC. NO.: 749C (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 978-657-0443 Address: 155 West Street, Suite 6 Wilmington MA 01887 Alt. Tel. No.: *Per M.G.L. c.147, s. 57-61, security work requires Department of Public Safety "S" License LIC. NO.: SSCO 001163 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: $06 1 Signature Telephone No. Date .... b.-.�� 0.F.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... 5_C, TT ................................................... has permission to perform ..:...... E�.�J�Q �(iv.............. .......................... ....... wiring in the building of ...............%.............................................. at T r orth Andover, Mass. °�o y�C� bwr Fee.—t"..-7... .......'.....Lic. No .............. ......................... ..........�.- ............... ... ELECIRICAL INSPECTOR Check #� 8166 h • La •-actssamusetts o�c;a� Use only Department of Fire Services IVPer No. !0 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked V 1/07 APPLICATION FOR PERMIT Tp ERFORM ELECTRICAL WORK n�veblank m All work to be performed accordance y�,i the Massachusetts Electrics] Code (PLEASE PRINT WINK OR TYPE ALL INFO (MEc), 527 CMR 12.00 City or Town of: NORTH ANDO'VHR ON). Date: y - By this application the undersigned gives notice of his or ..To the Inspector of Wires: Location (Street & Number) her mtemon to perform the electrical work described below. Owner or Tenant e Owner's Address Telephone No. Is this permit ,in conjunction with a binding permit? Purpose of Building Yes ❑ No ❑ (Check Appropriate Bog) E: istino S Utility Authorization No. Service Amps _/ _Vohs Overhead ❑ Undgrd ❑ No. of Meters New Service `amps / Volts Number of Feeders and Ampacity Overhead ❑ 1Jndgi d ❑ No. of Meters Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires No, of Luminaire Outlets No, of Luminaires No. of Receptacle Outlets No. of Switches --------------- No. of Ranges No. of Waste Disposers Vo. of Dishwashers No. of Dryers No. of Water Heaters KW 'No. Hydromassage Bathtubs of CeB•-Susp. (Paddle) Fans Of Hot Tubs mming Pool .Above d. Of Oil Burners o, of Gas Btu -hers o. of Air Coad. table maybe waived by the In ector of ppires. �� r Generators KVA o. o mergeney ALAS INo. of Zones of Alerfmg Devices Totals: "" =`=-- 1 ons & W o. of elf: Contained Detection/Ale 0 pace/Area $eat KW Devices nuts Local Connecttiion ❑other [eating Applisances KW Security Systems:* a No. of No. of Devices or Equivalent S. Si Ballasts Data W"a-ing: o. of Motors Total HP No. of Devices or E aivalent Telecommunications No. of Devices or F.�e..� Estimated Value of Electrical Work – Attach additions! detail if desired, or as �' �-d (When required by municipal policy.).required by the Inspector of Wirer. Work to Start Inspections to be requested in accordance with INSURANCE CO . VERAGE: Unless waived b the o _ MEC Ru 1 Q, and upon completion. the Iic=sm provides proof of liabilityY g oo o Per t for the performance of electrical work may sue mess undersigned c insurance includin entities that such cov a is in force, and has mpleted operation coverage or its substantia] e CHECK ONE: INSURANCE exhibited of of same to the equivalent The BOND 0. O per issuing office., I certify, under the paints and penalties o eR {Specify ) FIRM NAME: fP jury' that the information on this applicationis true and complete Licensee: S�,®,`p S LIC. NO.: (If applicable, enter exempt to the license number line.)$e'—`� �� Address: l _ _ LIC. NO.:yv *Per M.G.L c. 147, s. 57-61, security work requires B� TeL N°•: — oma! OWNER'S INSURANCE W eP�tnient of Public Safe Alt TeL Nn.:�y_��t�/G ATi'ER: I am a tY °S" License: Lic. No. -- required by law. B m signature u'� that the Licensee does not have the liability Y Y gnature below, I hereby waive this re tY insurance coverage normally Owner/Agent quirement I am the (check one) Signature owner [3 owner's agent Telephone No. ------------ PERMIT FEE: $ a } Comrrraaw ealflt ofMassachaseft j Department of AdustrW Accideft ' ice o 'Q ' 1 VX/ f laresftd afwnstSQQ Nlashirton Street ti Boston, MA 02111 r� Workers' ComPenatioWWW.masgaylda nIatraacEAftciaoBlders lCaApplicant Infa�afian tors/Eiectricians/PiQmbers Please Print Legibly N Bme (Bneinrss/Qjpniza6on/1ndMdU81Y 9, Address: CitY/Stat:zP: Phone #:.7F_ �os Are you an employer? Check the aPP • natehoz: 1•❑ Iam a employer with 4.ro P . 1 am a general contractor and I. NX -Of project (requited): employ= (fop and/or part_time).* . have hired the sib -contractors 6. [] Now construction I am.a.sole proprietor. or partner. listed ship and have no employees on the attached sheet; 7. ❑Remodeling These st6-contracim have working forme in any capaci , work 8 Q Demolition° [No workers' comp. i � �' comp. insurance. p insurance �. ❑ �Ve are a corporation and its - .9• ❑ Bw1ding addition required.] e . 3. Iain a homeowner do' ° have exercised their 10•&Electrical repairs or additions Myself o.w ca all work right of exemption per MGL 11.. (N ocicers' camp. ❑ Plumbing repairs or additions insurance P Q �� § 1(4�.and we have no required:] t .employees 12 Q jZoof repairs [No warkors *Amy appiicentthar comp. iTmuranc a Mquired..]: I3;[].O� checks bo�C# 1 mom also fin out the section blow showing their workers' bompwNdion Poiicy information t tiameownera who eabmitths fl�`idavit'indjrmting.&1Y ars dais an wo ;Cortanntow that check this box mustatta g rk and then hbe-outside eonoaetm mast submit s new an additional sheat showing the mute of the R•�-„---� affidavit indicating rudL I am art errrpioy� thaX. fS • rA u`vcs and their workers' comp policy inintmalion. inforn�on, g:warkers cotrtperrsatiirrn insarancefor artPloyea: Below is. the PO&J, and job site Insurance Company Name: Policy # or Self -ins. Lie. #: F.icpiraion Date: Job Site Addroskc Attach a copy of the.workere come Chl'/St Zip: PensaSon policy sfeciara�tiou page (showing the policy Dumber and expiration da4e Failure to secure coverage as required under Section 25A of 1 - fine up t4 $I. 00.00 and)or one -Year ' MGL C. 352 can lead to the imposition of c=inal Of up to $250.00 e Y imprisonment, as well as civil penalties in the form of a STOP VJQ p�tusities of a Investigations againstthe violator. Be advised that a copy of this eta%tuent May be fnrw RK ORDER and a fine �t gations of the DIA for insurance coverage verification. Y arded to the Office of I do hereby certify ander the pains acid penalties of per!ur, Haat the utformcfioR proves °6v1e IS true and correct Phone #: Date O, ffIch use onfy. Do not; wrrte iri this Dreg ln. be ea f mP a ed by city or town offirxo[ City or Town: Issuing Authority (circle one): PermitlL:icease I. Board ofri"itb Z Bufldi b Other Department 3. CitydTown Cleric 4. Electrical Inspector E. Plumbing fns pecfur Contact Person: Phone#: Information. a iZd Instructions Massachusetts General Laws chapter 1 S2 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, ass•oaiaiion, corporation or other legal entity, or any two or more ofthefioregoing engaged in a joint enterprise, and includirig the legal representatives of a d=ea=d employer, or the receiver or tnistee•of an individual, partnership, association or other legal entity, employing employees. 'Howeverthe owner, of a dwelling house having not more than throe apartments and who resides therein, or the occupant of the dwelling house of another who employs parsons to do maintenance, construction or n -pair work on such dwe{ting house or on the grounds or building appurten= thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, 925C(6) also states that "every state or- local fieensing agency shall withhold the issuance or renewal of a license or permit to operate a business or .*o constrnet buildings in the commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insurance coverage required" - Additionally, MOL chapter 152, §25C(7) states "Neither the commonwealth nor any of its -political subdivisions shall enter lino any contract for the performance of public work tMI-acceptablo evidence of compliance with the insurance roquirerments'of this chapter have been presorted 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 sdb-contractors) name(s), addrms(es) sand phone number(s) along with .their certificate(s)' of . instumce. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no.employees otherthan the members or partners, =not required to =,r5' workers' coTnpensafion insurance. If an LLC. or LLP does have empioyees, a policy is reginred. Be advised.ti-M this affidavit -maybe submitted to the Depas#romt of industrial kcaiderm for confmnation 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 regal -ding the lav, or if you .are requiped m obtain, a workers'• compensation policy,:pime call the Dgmtment at the nu'.raber.liisted below. Self-insured companies should enterthnr set iFesraance'.iieenae mintier on true appropriate ii=. City or .Towns 0fracisis Pie= be sure that the affidavit is complete and printed le'gibiy. 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 sura to fill in the permMicanse number which vc,ilI be used as a reference number.. in addition, an applicant thaf.m.ustsubmit multiple. permiOicesmse applications in arsy given year, need only submit one -affidavit indicating -current policy 'infb maiion (if necessary) and under "Job Site Adds-e;ss" the applicant should write "all locations in (city or town)." A copy of`Ihe affidavit that has been officially stmmped or marked by the city or fawn may be provided m the applicant as proof that a valid affidavit is on file for firm .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 t4• complete this affidavit ` The Office of lnvesEiptions would 155- to. thank you in advance for your cooperation and should you have any questions, please do not. hesitate to give us it call.. The Dmparment's address, telephone and. fax number. The Commonwealth of Massachusetts Depm-ftmnt of Industrial AccideatS Office of iavesskwsfions " 600 Washington Street Basion, MA 02111 Tvi. # 617-7274900 ext 406 or 1-8.77-MASSAFE }L,vised 5-26-05 Fax fi 617-727-7749 Www.mass.govldia