HomeMy WebLinkAboutMiscellaneous - 39 HIGH STREET 4/30/2018Town of North Andover
BUILDING DEPARTMENT
CONTRACTOR AFTER HOURS REQUEST FORM
CONTRACTORS NAME:
ADDRESS: '�"\ �� � (-, -�
CITY/TOWN: N A41P0VeP— STATE: M P zip: 0) & " 5--
1
BUS.PHONE: CELL: -3 3 ,--'-7
` h6rJ
7
MA. LIC #: MASTERS: JOURNEJXAXS- a -3 S- *14�L
PERMIT # C -A ?i N -GRID
REQUESTED DATE- (14-r)TIME: �'-f
JOB LOCATION:
OWNER: G Ma -L- L—�C--
PHONE: 1-7 WORKERS CELL: 7 3T1
REASON FOR REQUESTED INSPECTION AND JOB DETAILS:
NORTH ANDOVER SUPERVISOR SIGNATURE:
Contractors requesting INSPECTIONAL SERVICES due to weekend or after hour operations
such as service related planned updates or special situations, will be required to provide a four
hour minimum charge of $150.00 paid to the Town of North Andover at that time.
Community Development Division, 1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9545 Fax 978.688.9542 Web www.townofnorthandover.com
0 1, 1) n �' --k' '-) a I i
2-c"
P
t
Location
7
ate
No.
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee V��)
TOTAL $
Check
Building Inspector
61?
Date ..... 7 —7-' — / --,
. ................ ;=:� ........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .................... ........ .. . ....... .........................................
has permission to perform ..... .......
wiringin the building, of ................... .........................................................................
at ........ ........ 11.12 .................... / ... ........... .................................... . North Andover, Mass.
Lic. No.
Fee .... P" '.— ;� ...........
.......... �!QIL�E=ickL INspEcrm
Check #
�C\ Commonwealth of Massachusetts Official Use Only
11
PermitNo..
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/o7] aeaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perforined in accordance with the Massachusetts Electrical Code (hIEC) 527 CNM 12.00
(PLEASE PRTNTINMK OR YTPEALL INFORMMOA9 Date:
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) 1>7 —
Owner or Tenant IV 8
Owner's Address 12 r–?.–
Telephone No.
Is this permit in'conjunction with a building permit? Yes X No [j (Check Appropriate Box)
Purpose of Building zv/)� /)-Z Utility Authorization No.
- Existing Service _ Amps volts
New Service — Amps Volts
Number of Feeders and Ampacity
Overhead [j Undgrd [:1 No. of Meters
Overhead [j Undgrd Ej No. of Meters
Location and Nature of Proposed Electrical Work: PXY 16
Comnletion of the following table mav be waived bv the InsDector of Wires.
No. of Recessed Luminaires
No. of CeiI.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above Ei In- ---0
grnd. grnd.
No. of Emergency Lig ting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I N*o. 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:
KW ..........
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local E] Municippi n Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:* quivalent
No. of Devices or E
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 Eauivalent
OTHER:
Estimated Value of Electrical Work:
Attach additional detail if -desired, or as required by the Inspector oj w1res.
(When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with N1EC 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 operation7' coverage or its substantial equivalent. The
undersigned certifies that such cov
,prage is in force, and has exhibited proof of same to the permit issuing office.
CBECK ONE: INSLT-PA-NCE, N BOND 0 OTHER 171 (Specify:)
I certify, under thepains yndprenalfies t th!��ation on th is application is true and com
plete.
FIRM NAME: LIC. NO.: J4 /,-? & -7
Licensee: A (��711--A
(If applicable, enter "exenipt"
Address: ��.A4
LTC. NO.:f / /QxJ-7/
Tel. No.:
Al
*PerM.G.Lc. 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) El owner El owner's agent.
Owner/Agent
Signature Telephone No. MHITFEE.- $
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.
El 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 0
• Permit Extension Act — Permit/Date Closed: I
Trench Inspection
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
PARTLU ROUGH INSPECTION:
Pass n?
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass
Failed
Re- Inspection Required 0
Inspectors Comme� �-
(I C-101 0,4 If
A
7-
1 1 F - -r-
J
Inspectors Signature:
U
Date:
FINAL INSVCTION:
Pass M V/
Failed
Re- Inspection Required 0
Inspectors Comments:
444
Inspectors Signature: /&/�
d
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
The Commonwealth ofMassachusetts.
Department of JndustriqlAccW�ts
Office of Investigations
600 Washington Street
Boston, MA 02111
U www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
NaMe (Business/Organization/Individual):
Areyou an employer? Check the appropriate box:
1. KI am a employer with Z� 4. El I am a general contractor and I
employees (fall and/or part-time).*
have hired the sub -contractors
2.0 1 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. El We are a corporation and its
required.]
officers have exercised their
3.0 1 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. F1 New con ' struction
7. E] Remodeling
8. 0 Demolition
9. E] Building addition
10. 0 Electrical repairs or additions
11.0 Plumbing repairs or additions
12.E] Roofrepairs
13.[-] Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
i Homeowners who submit this affidavit indicating theygie doing all work and then hire outside contractors must submit anew affidavit indicating such.
tf,-ontractors 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 isproviding workers' compensation insuranceformy employees. Below is thepolicy andjob site
information. 'A
Insurance Company
V 411 -
Policy 9 or Self -ins. Lic. #: Expiration Date:
Job Site Address: Citv/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.
hereby cert! under the s :�ft,
fy ofperjury that the information provided above is true and correct.
Simature: Date:
Official use only. Do not write in this area, to he completed by c4 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#:
A
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 ofhire,
express or implied, oral or written."
An employeris defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint 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 (LLQ 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 fille ' d 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 p* ermit 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
Tel, # 617-727-4900 "t 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
--www-mass.govidia
Date ...... 8.-..7-1 ... 5.
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .................
...........................................................................................................
has permission to perform ........
..................... .. . . ... .......... ......
wiring in the building of....
.r . ................................
at
Fee ...... ...... �ic. No.
C+k #
.,,Lcrth Amdover, Mass.
x
ELE, ile . .. .... ..
./ 7
2aparintant a/-7ira Sartlicad
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.
Occupancy and Fee Checked
I[Rev- 11071 (leave binnk-)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be! pe�rbrrned in accordance -Mth the Massachusetts Electrical Code (ME9, 527ft-UR 12.00
(PLEA E Date:
By this To the Insp�ctor"ofITh-es:
"P7 0
a f
appz %onS dersi'gp dlpi �����erfbrm the electrical work described below.
Location (Street & Number) j z
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction %yith a building permit? Yes NoK (Ch eck Appropriate B
Purpose of Utility Authorization No._
Existing Service Amps I Volts Overhead F1 UndgrdE]
New Service Amps I Volts OverheadEl Undgrd [_]
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Worla
No. of Meters
No. of Meters
table maip he ivahled hip the Inspector of lVires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers le -VA
No. of Luminalre Outlets
No. of Hot Tubs
Generators JCVA
No. of Luminaires
Swimming Pool Above " In-
arnd.L-1 grnd.
0- ol Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
F IRE, ALARMS
lNo. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initinflug Devices
No. of Ranges
Total
No. of Air Cond. — Tons
No. of Alerting Devices
No. ofWaste Disposers
Heat Pump
Totals.,
N mber I Tons
I
I 1-1,W
No. of Se[F-Contained
Detection/Alerting Devices
—
I —
No. of Dish'wasbers
Space/Area Heating 1CW
Locntf3-P(unlc'pPl —fj�ther
onnectian
No. of Dryers
Heating Appli . ances av
Security Systems:
No. of Devices or Equivalent
No. of Water ICW INo.
Heaters
I
of No. of
signs Ballasts
Data Wi 'in
f Dgevices or Equivalent
No. o'
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wirin
No.ofDevires-orEqui ent
V nj:
I
OTHER:
iltlach additional derail ifdasired, orarrequiredby the b7speclarofffrirw.
Estimated Value of El c al Work: ��� b60 (When required by municipal policy.)
Work to Stardt: Inspections to be requested in accordance with MEC Rule 10, and upon Completion-
INSURANCE- -C-6VLFRAGE,.---Unless-waived-by-the-owneri-no-pe�rinit-for-the-perforTnance-ofeler-trical-worit-may-isstir, unJess.
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 proDfofsame to the permit issuing office.
CHECK ONE: INSLJRANCE F1 BONDF1 OTEER 0 (SpecTy:)
Icertijjl,z,r,ridartliepatizsatzdpenalt!L,sofperjrt,ry,fliattlicitiforillatioll,,ggtl,jisapplicul'lolz strueandcontplete-
FMM NAME: Interstate Ejectrj-caj Seryi-ces Lit. NO.: A-5217
Licensee: Pasqtk-Ae A. Alibrandi- Signature LIC. NO.:
(Yawlienble, ente " n7p. M -die lic se rzuijerj...�Verc�a - T-/ L,'-fZ1111V Bus. Tel. No.z 9787947=3130
Address: r�6p-lfreae U V I . I MA 01862 ' Alt. Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security work requires Department ofPubife Safety "S" License: Lie, No.
ONVNER'S INSURANCE WAIVER: I am aware that the LicBnsee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check onr,)EI owner El owner's a e L
Owner/Agent
Signature Telephone No. PERWT FEE.- S
I'he Commonwealth oj'Massachusetts
Department ofIndustrial Accidents
Office of Investigations
.1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant In formation Please Print Legibly
Name (Business/Organization/Individual): Interstate Electrical Services Corporation
Address:70 Treble Cove Road
N. Billerica, MA 01862
Phone #:(9-78) 947-8130
Are you an employer? Check the appropriate box:
I.X I am a employer with 500,
4. EJ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. 1 am a sole proprietor or partner-
E]
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. insuranceJ
required.]
5. EJ We are a corporation and its
3. E] 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 required.]
Type of project (required):
6. E] New construction
7. F] Remodeling
8. E] Demolition
9. r-1 Building addition
I 0,�< Electrical repairs or additions
ILEJ Plumbing repairs or additions
12.F� Roof repairs
13.M Other
I
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homdowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employLs. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy andiob site
information.
Insurance Company Name: American Guarantee & Liability Insurance Company
Policy # or Self -ins. Lie. #:WC583359000 Expiration Date:09/30/2013
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 herebv cerd,9 under diepains and
— - 1/ -,01 / -
that the information provided above is true and correct.
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#:
Date..i �)�
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..... z le C:� C) C/a, C/S / 4 /.��
.......................................................................................................................
has permission to perform ...... ......
wiring in the building of..C�Y ... /!�6
..... ..... ...
at ..........
.................................... . orth Andover, Mass.
Fee,41?.S ... —d�o .......... Lic. No. ILIA . .............. .
................... . .. ....... .. ......................
ELEC-MCAL INSP OR
�3
C hec
1 1
Commonwealth of Massachusetts Official Use Only
Permit No.
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00
(PLEA SE PR TNT IN INK OR TYPEA LL MFOR M,4 TION) Date: ?L& I / -�
City or Town of.- NORTH ANDOVER To the lns,�ect& of Wires:
By this application the -undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) /6�-c
,/� S—, —
Owner or Tenant Cd,�-Q- TelephoneNo. 92J' ko
Owner's Address 14i"?111 JP;- A 41VOCIV&Z A 4- 0/,Fly�
Is this permit in'conjunction with a building permit? Yes No F1 (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service -1671A— Amps volts Overhead [I Undgrd [j No. of Meters
New Servic Amps Volts Overhead [I Undgrd [I No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
pc ogaT Zy Yd ZC441YA
Comnletion ofthe following, table ma -v he waived bv 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 Ei In- Ej
No. of Emergency.Ligliting
grnd. grnd.
Battei�y Units
i No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
JN'o. of Zones
No. of Switches
No. of Gas 13 urners
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
I.KW ..........
No. of Self -Contained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
LocalE] Municippl [:1 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 ib
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Enuivalent
OTHER:
.4tiach additional detail i(desired or as required by the Inspector of Wires.
Estimated Value of Electrical Work: OOD (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with NMC Rule 10, and upon completion.
INSURANCE e(WERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
tlie licensee provides proof of liability insurance including "completed operatiorP coverage or its substantial equivalent. The
undersigned certifies that such coyrage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE F1 BONDE] OTHER 0 (Specify:)
I cerilry, under thepains andpenalties ofperjury, that the information on this application is true and complete.
FIRMNAME:
LIC. NO.: *
Licensee: Z,)41 -f LTC. NO.:
,, A 4 6;y<U y, Signature 4"~
(Ifapplicable, enter "exempt" in the license number line.) Bus, Tel. No. - (Vd) fVY -116'el
Address: 36 604P-13�<� L-0 M A IX a. 44.21 Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-6 1, 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) El owner El owner's agent.
Owner/Agent
Signature Telephone No. PPRMIT FEE: $
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the W -
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.
El Rule 8 — Permit/Date Closed: Note: Reapply*for new permit 0
0 Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass M
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass IN
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass F?]
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass F?]
Failed
Re- Inspection Required El
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass
Inspectors Comme
3e2
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
The Commonwealth ofMassachusetts
Department of JndustrialAccWnits
Office of Investigations
600 Washington Street
Boston, MA 02111
Uf www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): eAll
Address: 3 4 Zv fp7rgiv _ryyp p, X
City/State/Zip: j�gd&rl-2:vq 0,2�f,2/ Phone 4: (�Ijo) ?93 111 V
Are y. I an employer? Check the appropriate box:
1. 171 aim a employer with
4. El I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2.0 1 am a sole proprietor or partner-
listed on the attached sheet
ship and'haveno employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
required.]
officers have exercised their
3111 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. Remodeling
8. Demolition
9. E] Building addition
10. n Electrical repairs or additions
1LE] Plumbing repairs or additions
12. Roofrepairs
13F] other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
i Itimeowners who submit this affidavit indicating they aire doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
Iam an employer that isproviding workers'compensation insuranceformy employees. Below is Iftepolley andjob site
information.
Insurance Company Name:. -577- IAL9.r 7144vi-&-lif
Policy # or Self -ins. Lic. -0 Z 3 6 2 WS Expiration Date: &&Oa
Job Site Address:— Z h�cy 5—,, CitY/State/Zip:__,4/A4,&ar4J A.4. 01W5�_
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
Inyestigations of the DIA for insurance coverage verification.
-1 do hereby certify under thepains andpenalfles ofperjury that the information provided above is true and correct.
Si ature: Date: 2AL/13
?113 -ill
Official use only. Do not write in this area, to he completed by c4 or town official
City or Town:
Permit(License 9
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact
Phone N:
A
Information and Instruction --s
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 ofhire.-
express or implied, oral or written."
An employerls defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint 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 ofpublic 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-contrartor(s) narne(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ 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 eater 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.
Pleas ' e 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 p* ermit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations I 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 ladustrial Accidents
Office of Investigations
6 00 WasMngton Street
Boston, MA 02111
TQL # 617-727-4900 ext 406 or 1-877rMASSAFE
Revised 5-26-05 Fax # 617-727-7749
__www-mass.gov1dia
Ail
This certifies that ....
has permission to perform ..........
plumbing in the buildings of
at s
...................... Nor�4 And7er Mass'
Fee Lic. No. .............
PLUMB11 INSPECTORY
Check
P
TYPE OR
PRINT
CLEARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY [/,
MA DATEI,_ PERMIT# ]WIL
JOBSITE ADDRESS 13 9_ OWNER'S NAMEj_C,,,4_,_j/e rL�g—, S4
OWNER ADDRESS FAX
OCCUPANCYTYPE COMMERCIA140 EDUCATIONAL RESIDENTIAL El
NEW: 0 RENOVATION -E] REPLACEMENT: [I
PLANS SUBMITTED: YES[j NO[j
INSURANCE COVERAGE:
I have a current liability nsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTf4ER TYPE OF INDEMNITY [j BOND El
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: OWNEREJ AGENT El
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this applicago'n are Oue and accurate o he best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will ei o lianc rti ' rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE #F6E85:T_j-- SIGNATURE
MP El ip CORPORATION E1#1 398C �JPARTNERSHIPE
]#�� LLcF J#
COMPANY NAME jka�-qeI'qo.,,Inc. ADDRESS 1.15_C a��fqo�q S
L
CITY F-ja�te�owL STATE [7:iA:_:] ZIP [-
?�72 TEL [�1�7-923�qjj
FAX j61:U?6-�_74q_ CELL EMAIL Eat�ypLe@qan-cel.com
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08/08/2013 10:05 FAX
10-W
U0002/0002
.-COMMONWEALTH OF MASSACHUSETTS
PLUfASERS AND GASFITTER
I E .-FD AS A MASTER PLUMBER
IsSUES THE ABOVE LICENSE TO:
ELLGCCI
TON PD
MA 01773-2310
i
7 '168041
Fold, Then Detach Along AD Perforations
Date .......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ......... ... 1) . .....
............ .............
has permission to perform .......
..... �P�
......................
wiring in the building of ...... ..... .............................................
........................................................................... Jiorth Andover, Mass.
. .... ................
F�w ..... No.
Check _72?
'! 17 8 1
1*
Commonwealth of Massachusetts Official Use Only
0.
Department of Fire Services Permit N
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 11/991 (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 INFORMA TION) Date: August 6, 2013
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) 39 High Street East Mill
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service Amps V olts
New Service Amps Volts
Yes No El (Check Appropriate Box)
Utility Authorization No.
OverhcadF� Undgrd No. of Meters
Overhead [:] Undgrd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Kitchen power wiring
Job 772
No. of Recessed Fixtures
No. of Lighting Outlets
No. of Lighting Fixtures
No. of Receptacle Outlets
No. of Switches
the
No. of Ceil.-Susp. (Paddle) Fans
No. of Hot Tubs
Above o
Swimming Pool ffrnA
3 No. of Oil Burners
No. of Gas Burners
table may be waived by the Inspect
No. of Total
Transformers KVA
Generators KVA
El11N o. oi hmergency
Battery Units
FIRE ALARMS I No. of Zones
Initintina Devirp.q
Wires.
No. of Ranges
o. of Air Cond. Total
Tons
No. of Alerting Devices
Heat Pu p
Num..b.er
[Tons
No. of Self -Contained
No. of Waste Disposers
Totamls:
'** *
I
I ... ... .. .. ..........
1KNy ..........
Detection/Alerting Devices
No. of Dishwashers Space/Area Heating KW Local [:] iviunicipai 0 Other
Connection
No. of Dryers Heating Appliances KW Security Systems:
No. of Devices or Equivalent
No..of Water KW 1.5 No. of No. of Data Wiring: '
Heaters Siens Ballasts No. of Devices or Eauivalent
INo. Hydromassage Bathtubs I No. of Motors Total HP a r Vnuiv a I pnt
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
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 Z BOND F] OTHERE] (Specify:) Selective Insurance Company 4/23/14
(Expiration Date)
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.
I certify, under th e pains and penalties ofperjury, that th e in/o manon on this application is true and complete.
FIRM NAME: D&D Electrical Contractors, Inc. / D =Ca lina Technolkies i LIC. NO.: Al 1933
Licensee: Douglas P. Lynch Signature 1C t�2� LIC. NO.: 24594
(Ifapplicab7e—, enter "exempt" in the license number line.) Bus. Tel. No.:781-932-0707
Address: 10 Everberg Road Woburn, MA 0 1801 Alt. Tel. 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) 1:1 owner [:1 owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE. $125.
2-0
N
.0
I
The Commonwealth of Massachusetts
Department ofIndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): D&D Electrical Contractors, Inc.
Address: 10 Everberg Road
/State/Zip: Woburn, MA 01801
Phone#: 781-932-0707
.re you an employer? Check the appropriate box:
I am a employer with 60 4. F1 I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
F_J I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees Thesc sub -contractors licave
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.:
required.] 5. F� We are a corporation and its
3. El I am a homeowner doing all work
myself [No workers' comp.
insurance required.] f
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comi). insurance reouired.]
Type of project (required):
6. F� New construction
7. E] Remodeling
8. E] Demolition
9. D Building addition
IO.N Electrical repairs or additions
I I. D Plumbin g repairs or additions
12.R Roof repairs
13.R Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t 1�omeowners 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 isproviding workers' compensation insurancefor my employees. Below is thepolicy andjob site
information.
Insurance Company Name: Selective Insurance Company
Policy # or Self -ins. Lic. #:
Job,,Site Address
WC7993614
39 High Street East Mill
Expiration Date: 4/23/14
City/State/Zip: North Andover, MA
AtOch a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Fail4ire to secure coverage as required under Section 25A of M.GL c. 152 can lead to the imposition.of criminalpena.1ties 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 her<b—yceKdfy under the pqins aq#penalties ofperjury that the information provided above is true and correct.
August 6, 2013
Phone#: 781-932-0707
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#: