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HomeMy WebLinkAboutMiscellaneous - 38 GREEN HILL AVENUE 4/30/2018k �J� Pu" iviassacnusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the ermit 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 shallbe limited as to the time of -ongoing construction activity, and may be -deemed -by the -inspector -of _Wires abandoned-and_inualidafbe—.. _ 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 extending1hrough August 15, 2012. Rule 8—Permit/Date Closed: % ** Note: Reapply for new pe rmi 0 Permit Extension Act — Permit/Date Closed: This certifies that .!�?-tti� P, �, L?lul i' x'11 �! �nN� ................ has permission to perform ..... .1 e � b.emm?. . wiring in the building of rN?- ......................... at ....` ..?� �! ..�.., ... , No 1h, Andover, Mass. Feb .J. Lic. No. ..... . ELECTRICAL INSPEC OR Check #�� 11066 A 11 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Ofci 1 se Only Permit No. 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 ININK OR TYPE ALL INFORMATION) Date: 7— y _ .1--C9 I Z., 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) Owner or Tenant 11%441(- Telephone No. Owner's Address 9 t� Is this permit in conjunction with a building permit? Yes h4 No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ 2e - 11 No. of Meters _ No. of Meters _ Adcld .cam, ttda r. Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: (Paddle) Fans of Total TransSusp. Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- El rnd. rnd. o. o mergency Lighting BNo. Units No. of Receptacle Outlets �' No. of Oil Burners FIRE ALARMS No. of Zones No. of SwitchesNo. of Gas Burners No. of Detection and Initiatin Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Dis posers P Heat Pump Totals: Number Tons ........... 1---*- 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 Dr Y 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 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: V y j a i L 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 a pains and pe ies of perjury, that (lie information on this application is true and complete. FIRM N E: 1--(.e "k LIC. NO.: i rV) L3 Licensee: �j aacl.1 Signature IC. NO.: 9 f t ZJ (If applicable, enter "exempt" in the license number line) Bus. Tel. No.: 7J -t -2s/Y -�Y i1 7 Address: 3-1 L et -&-k 14",Z— LN v-.-- J"* fylAlt. 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/Agant PERMIT FEE: $ Signature 'Telephone No. Re-xuspor-MA req*ecX($50.(q •- C I SQ (Cuspecto yzgaaiuxe " of -) Pate - 3passeaLrI X`ailea� -[ I nspectioxtxe[ uixec ( 0.00)•-C iz5 iectun c(lnYntextts: ftsl actors' ftnature - )io xxtitials) Slate Passed— j �ailec�--j � �te�fnspeetzo�xe��tzreu�(��0.00)"C � rnspectozs' coxam.ents: (lnsp aetoxs',ignaiure o �nitals) Pate RIVE NAME: Re-Inspaction. required ($50.00) " [ spectbxs9 coJmmep:fs: (fusp ectoxs' ,gzgaatuxe - io initials) Date, serf-[)�+,'aifer�•,[ �. '�te�aspectiottxeguire�,050.00)"[ � - 78et0?•�� COD17d��71tS: � • . 'Ohs ectoxs' Ozgnatuxe - no Initials) . Pate `1e-�■ pA u�uy �qj )) yy--�. }-�.{-(a/�, y(--��/-� {� 7- ,T�{ PIN T �.1��ytl�i UFT pA�V�Q'.�� �yyT(-p�-�y{(; yy-��-{(4 �.{y�'"-per}' y[--�[�{{;y� y��"���y{�(�--��y`��(,p�y��x { �y-`( n^■ LIR T+��+.�YN AM .+� V 13Y �MLED P IJ .i ✓.�+. l++ J�+�.S: Jl LJ.41 F+. TP .uti J.JPX A .4 ® ✓.i(.n-�. 1 Nl..+�'+YrY �� S NOT The, Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Amlicant Information Please Print Le�ibl� Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: 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. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship 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 These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp, insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. 0 Demolition 9. ❑ Building addition 1011 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑Roof repairs 13.❑ Other rr•--W-• •••�� �•_��� UVAn. 111U,1 awv un out me section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they ace 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. Lic. #: Expiration Date: Job Site Address: 1City/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. I do hereby cert under the pains andpenalties of perjury that the information provided above is true and correct. Signature: Date Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitUcense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector 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 bean 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 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 permittlicense 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 Comiponwealth of Massachu setts Department of Industrial .Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel, # 617-727-4900 ext 406 or 1-877,MASS.A.k'B Fax # 617-727,7749 Revised 5726-05 www.raass.�o�fd� _. Date..43.......01.14 ..................... ......... TOWN OF NORTH ANDOVER .PERMIT FOR.GAS INSTALLATION This certifies that ....... . .. .......... ... ... ......................... ....... ...................... ............. has permission for gas installation PY . . ........... 4....!. in the buildings of ................. ..... ....................................................................... m jQe-- North Andover, Mass. at z4t5 n ........................................................................ Fee -6,.C5.D. Lic. No. ...... 45.� ..................................................... ........... ... GAS INSPECTOR Check # 9257 f'� t VVUj u - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY North Andover MA DATE4/15/2014 PERMIT # JOBSITE ADDRESS 38 Green Hill Ave OWNER'S NAME G _ E OWNER ADDRESS Same TEI�— FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL PRINT CLEARLY NEW: ® RENOVATION: ❑ REPLACEMENT: ❑ APPLIANCES -1 FLOORS- BSM BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT UNIT HEATER UNVENTED ROOM HEATER YVATER HEATER [– RESIDENTIAL E] PLANS SUBMITTED: YES[] NO❑ 10 1 11 1 12 1 13 1 14 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND 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. CHECK ONE ONLY: OWNER ❑ AGENT SIGNATURE OF OWNER OR AGENT 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 in colance with all Pertinent provision of the 11 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / e IAA PLUMBER-GASFITTER NAME 1 Joseph Marino I LICENSE #18736 t-/"/ 9 SIONATORE MP MGF ® JP JGF ® LPGI ® CORPORATION 0# 3285C PARTNkf:&IP❑# LLC ❑# COMPANY NAME: RH White Construction Co ADDRESS 41 Central St CITY Auburn STATE MA ZIP 01501 TEL (508) 832 3295 FAX 1508-926-4347 CELL 508 832-4614 EMAIL JMarino@RHWhite.com I . \/ NNQ A\, -o\\ w F O z z 0 F U W a d z w az° z � w � w O w O F a z (A Cl) w a w R: O w d W C/3 a C7 zz A" d F- a a � U x F a a v, Q � w x w U - (0) W F O � z o H � � a z Ln x c� a° 3,q vim. Vv, iV,.� yam. u -r V Vvv..ILV I ..IL 1\I I WI Ll. 11- VUI 11) I I\UU I r HUE- UL/ UL , ACQR4.0 __JPATE (MMIDDlYYYY) .J CERTIFICATE OF LIABILITY INSURANCE;,,,, 1 of 08/29/2013 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the polioy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A Statement on this certifleate does notconferrights to the certificate holder in lieu of such endorsement(s). willia b£ Massachusetts, Inc. C/o 26 contury Blvd. R. 0. Box 305191 Nftmhville, TN 37230-5191 R. H. white Construction Company, rnc. 41 Central Street P. 0. Box 257 Auburn, MA 01501. 10-QML WEND), ND)_ 868-46-772378 cexCificate0C�w�illie.com INSURCR(8 AFFORDING COVERAGE NAO rt ERA: The Chartsr Oak rixe Ineurancg Company 25615-001 ERB: Tr-01Ars Property Casualty Cothpany of Am 25674-003 ERC: National Union Hlirg Insuranaa Company of 19445-001 ERD; Travelers Indamtity Company 25658-DO1 ■ �..r.��u t r.K I II-IL:A I C NUIY)bbW 20287680 REVISION NUMBER,, THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTJL NSR TYPE OF INSURANCE DD SU6 POLICY EFF POLICY EXP POLICY NUMBER LIMITS A GENERAL LIABILITY VTC2OCD 97789948-13 9/1/2013 -9/1/20314 EACMODCURRENOE $ 2-000.00E D WORKERS COMPENSATION AND EMPLOYERS' LIABILnY i1 ANY PROPRIETOR/PARTNERIEXECUTIVE NIA OFFICER/MEMBER EXCLUDED? below Evidence of Inourance 977K955A-13 9/1/2013 9/1/2014 BE8766140 9/1/2013 9/1/2014 VTRKUB 8205AIOS-13 19/1/201.3 19/1/2014 9/1/2014 VTC2XUB 9203A71A-13 9/1,/3013 Remarke more ep eco MED EXP (Any one arson PERSONAL&ADV INJURY PRODUCTS-COMPIOPAGG 2,000.000 BODILY INJURY(Perpemon) Is BODILY INJURY(Peraceldent) $ AGGREGATE E.L. EACH ACCIDENT s 1, 000 000 E.L.DI2EASE-EAEMPLOYF.E S 1,000,000 F.1.DISEASE- POLICY LIMIT S 1,000,000 SHOULD ANY OF TWE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRE86NTATIVE C*11:4197604 Tp1:7.694012 Cert:20267680 ®1988-2010ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD X COMMFRCIALGENERAL LIABII.17Y CLAIMS -MADE OCCUR GEN'LAGGREGATF LIMITAPPUES PER; POLICY PRO LOC B AUTOMOBILE LIABILITY X ANYAUTO A0611 OWN SCHEDULED X HIRCDAUTOS X NON -OWNED AUTOS X ComDad X C911 Ped C UMBRELLA LIAR $ OCCUR aG EXCESS LIAa CLAIMS -MADE DED I $ RETENTIONS 10,000 D WORKERS COMPENSATION AND EMPLOYERS' LIABILnY i1 ANY PROPRIETOR/PARTNERIEXECUTIVE NIA OFFICER/MEMBER EXCLUDED? below Evidence of Inourance 977K955A-13 9/1/2013 9/1/2014 BE8766140 9/1/2013 9/1/2014 VTRKUB 8205AIOS-13 19/1/201.3 19/1/2014 9/1/2014 VTC2XUB 9203A71A-13 9/1,/3013 Remarke more ep eco MED EXP (Any one arson PERSONAL&ADV INJURY PRODUCTS-COMPIOPAGG 2,000.000 BODILY INJURY(Perpemon) Is BODILY INJURY(Peraceldent) $ AGGREGATE E.L. EACH ACCIDENT s 1, 000 000 E.L.DI2EASE-EAEMPLOYF.E S 1,000,000 F.1.DISEASE- POLICY LIMIT S 1,000,000 SHOULD ANY OF TWE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRE86NTATIVE C*11:4197604 Tp1:7.694012 Cert:20267680 ®1988-2010ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... - --- --------- has permission to perform .. 9 .. wiring in the building of .... .............................................. a.,.e . ........ . North Andover, Mass. Fee ... Lic. ....................... CrOR Check # 7507 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. —y� -1 Occupancy and Fee Checkeda 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 (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Q'} -09 -p-:� City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to,pgrform the electrical work described below. Location (Street & Number) %4 Owner or Tenant MA-nJE--7J WKNEM Telephone No. 391- -qR-A Owner's Address SSL Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. c2E,3 /S 7 Existing Service / 00 Amps 20/ 2zlo Volts Overhead N Undgrd n No. of Meters i New Service 23® Amps / 2-0 / 2-yO Volts Overhead ® Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: d0zvr- VPC -m06- Co!e!inn of Picot n..,..:»..t,.t.l.,........ L_..._:.._J �-.r-_r-__--_-.- rr.r• -- No. of Recessed Luminaires F1 No. of Ceil: Susp. (Paddle) Fans "- Irg"y tic w"Imu Uy int: 1Ie(;tUrU rr tres. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above1:1In- ❑ o. o Emergency Lighting rnd. rnd. 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 Imtiatin Devices No. of Ranges No. of Air Cond. Total Tons No, of Alerting Devices g No. of Waste Disposers Heat Pump Number Tons ....... . KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Water No. of No. of No. of Devices or Equivalent Heaters KW 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: ®Q. �� (When required by municipal policy.) Work to Start: 0-4-Ja "'R 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 P BOND ❑ OTHER ❑ (Specify:) I certify, under thepains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: _KcV/A/ M , M I U( (4AJ Signature!'"'� LIC. NO.: 332.1 O C (/f applicable, 202_ n:p�' in t{ie license number li e. Bus. Tel. No.: •' Address: (h,��} � �$�© 1��3 Alt. Tel. No.: -Z -0h?- *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 Signature Telephone No. PERMIT FEE. $ � S eP'Li - Hdl�o r 1-11 WIJ Z�#� -e7 /`1-K The Commonwealth of Massachusetts Department of Industrial Accidents Office of In vestigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers DDUCant Infnrmntinn Name (Business/Organizadon/Individual): t!:�EU/N ►M . (M ( (_(_ (C-/� Address: Zo-L wa!M1a/, f t�- City/State/Zip: A/, Clf�r�2S�Oo�� v� Phone. #: 979-2S7-0819 Are you an employer? Check th e appropriate box: /Il 1. I am a employer with 4. ❑ I am a general contractor and I q employees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet ship and have no employees These sub -contractors have working for mem any capacity. employees and have workers' [No workers' comp, insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 3. ❑ I am 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 re uir d. Type of project (required):. 6. E] New construction 7. El Remodeling 8. ❑ Demolition 9. C] Building addition 10.2.Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.[] repairs 13.❑ Other 'Any applicant that checks box #1 must also fill out the section below showingtheir w e ] l I cc, sa t Homeowners who submit this affidavit indicating they are doing all work and then hiree mpen tots mus subon Policy mit nom, affidavit indicating such. tContractors that check this box must attached an additional sheet showing die name of the subcontractors and state whether w not those entities have employee. If the subcontractors 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 informadon. Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: �SS7 ULs N . ��f7 Duce) 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 ofMGL 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 maybe forwarded to the Office of Investi¢ations of the DLA for insurance coverage veriRroN.,,. I do hereby certifyy under the pains and pp/enalttes of perjury that the information provided above is true and correct n • _ moi' _ -. .-z __ � _ //% use area, to 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. Ph,rnhins r—...,_6.._ 6.Other Contact Person: Phone #: Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..................................................... Sw .............................. has permission to perform r ..................................................................... wiring in the building of ..................... akale— at ... ..................................... North Andover, Mass. /6....... ............ 4 ......... Fee .-?�/ /..0.... Lic. No. /�//Y7 ........ ELECTRICAL INSPECTOR Check # 5461 tf�lr The Commonwealth of Mas; 7 1 Department of Public Safety L� BOARD OF FIRE PREVENTION REGULATIO? APPLICATION FOR PER T{ M work to be Wftff rod intiiccordence (PLEASE PRINT IN INK OR TYPE ALL INFORMATION City or Town of lV17 Ld` Lr/1 Tire undersigned applies for a permit to perform the Location (Street & Number) ?-a LL IC usetts Office Use Only Permit No. 527 CMR 12:00 occupmcyr a Fee Checked��_� 3190 peeve ttlenk) ) PERFORM ELECTRICAL WORK the Massachumits Electrical Code. 527 CMR 12:00 Date below. .To the Inspector of Wires: Owneroofowt �'�' G�� �bC `�7L Owner's Is this permit in conjunction with a building permit yg yes ❑ no Purpose of Building l i`3 utility Existing Service Now service Number of Feeders and Amps / Voits Amps -----/-Vohs Location and Nature of Proposed Electrical (Ch-;kppropriate Box) Authorization. No. _J0 44 - Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters. No. of fighting Outlets No. of Hot Tubs TOTAL No. of Transformers KVA No. of Lighting Fixtures Swimming Pool Agmd,bove ❑ In d ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners / No. of Emergilincy Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Sell Contained OetectionlSounding Devices it� Local EJConnMuntttdiopaln ❑ Other No. of Ranges TOTAL No. of Air Conditioners TONS No. of HEAT TOTAL TOTAL No. of Pumps TONS KW No. of DishwasherstrelArea Head KW No. of HootingDevices KW No. of Water Heaters KW No. of No. of Stgns Ballasts Low Voltage lWiring No. of Hydro MassaV Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Po" including Completed Operations Coverage or its substantial equivalent. YE ' : NO 0 1 heave submitted valid proof of earns to this office. YESNO C ncl It you have Checked YES, please ithe type of coverage by checking the appropriate box. INSURANCE N BOND ❑ OTHER ❑ (Please Specify) _ (Expiration. Date) Estimated Value of Electrical Work$-ZO Work to Start— 140 Inspection Date Requested: Signed under the p aittes f perjury: FIRM NAME ANDREW F SHEEHAN ELECTRICAL Licensee Andrew F. Sheehan Signature NO. A11498 LIC. NO.A11498 Address 249 Pine Hill Road/ Chelmsford, Ma 0182a Bus. let. No( 97811256-8740 Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or Its substantial equivalent as required by Massachusetts General Laws, and that my signature on this application waives this requirement. Owner Agent (Please check one)