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HomeMy WebLinkAboutMiscellaneous - 4 EAST WATER STREET 4/30/2018Date ... 0.�/ .................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that .'� .. ........................... ................ .... ...................................... has permission to perform ;L=;.1 ............................................................................................. -- & dL.- winng jn the building of / ... U..� .. ............... .... ..... le -"e j ' orth Andover, Mass. . ....................................................................................................... . A FeeA .. . ......... Lic. No . . ............ ..... ELECI�Uir A�S�KCT� Check # 16 L/ -3 /�ommonweaGCDD,,h. // ol Ma6�ach/u�e� Official Use Only Ccc• a1.JePartment ol,}ire Jerviced Permit No. / ��7� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [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 IN INK OR TYPE ALL INFORMATION Date: / City or Town of: �M-by,11IR To the Inspector of Wires: By this application the undersigned ge es notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner 'or Tenantjos i1a /4 Telephone No. Owner's Address 17 S- % Z- C) Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building - Iog , l,�-� � �/ Utility Authorization No. ` Existing Service jgr Amps 42,Volts Overhead Q' Undgrd ❑ No. of Meters New Service •t24&2 Amps /nib /.,JAl (Volts Overhead ❑L' Undgrd ❑ No, of Meters Number of Feeders and Ampacity �rrRs No. of Recessed Luminaires No. of CeilSusp. (Paddle) Fans : No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires SwimmingPool Above ❑ In- 1:1 rnd, rnd. o. o Emergency Lighting . Battery Units Na. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of'Switches No. of Gas Burners o. of eteng D and Initiating Devices No. of Ran es g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: umber _............._........._- Tons KW y - No, of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑Municipal ❑ Other Cyyonnection No. of Dryers Heating Appliances KW SecNo of Devices or Equivalent No.. of Watero. Heaters KW of No. of . Signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications firing: 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: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAG : 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 cov ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) I cer4&, under the pains and penalties of perjury, that the information. on this application is true and complete. FIRM NAME: `/ i�b� �G�%•9i ' c LIC. NO.: - Licensee: % , �� 2VrgC� Signature _ y� LIC .: (Ifapplicable, enter ' exempt" in the license number line.) Bus. Tel Address: 11. /�8.� �i /� P%�ill�� �i/�, D/ � Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department -6f Public Safety "S" License: Lie. 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 a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ �f U. `. The Coninionivealth ofMassachusetts Department of l►rdustrial Accide►rts Office of Investigations 600 Washington Street Boston, MA 02111 fvww.►nass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leyibly Name (Business/Organization/Individual): ael&-60 eG / �!5�2e 1/. ,,m4 Phone7 / • Are you an employer? Check the appropriate box: 1. ❑ I am demployer with Y 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 These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' cornp. insurance 5. ❑ We are a corporation and its required.] ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t officers have exercised their right of exemption per MGL c. 152, § 1(4), .and we have no employees. [No workers' comp. insurance required.] Type or project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.[!],'�leetrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other *Any applicant that checks box ff 1 must also fill out the section below showing their workers' compensation policy information: t Homeowners 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 their workers' comp. policy information. I am an employer that is providing workerscompensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -his. Lic. #: 40 0?9 Expiration Date: Job Site Address: Td :7- Wa aA `'7 City/State/Zip: �,11, 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 ofcriiiunal 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 certify under the pains and penalties of pcijury that the information provided above is true and correct Oficial use only. Do not write in this area, to be completed by cit), or towh official. City or Town: Issuing Authority (circle one): 1. Board of Health Z. Building Department 6. Other Perrnit/Licerrse # Cityrrbwn Clerk 4. Electrical Inspector 5.. Plumbing Inspector Contact Person: Phone #: Date.Z ....... z ...... 1-,/ ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ............................ ........ ........................ ............................. has permission to perform .......... .,? ...... ................................... ........... . . .. .... wiring in the building of ... :f�� .......................................................................... at............................................................................... . NorthAmdover, Mass. I Fee .... .................. Lic. No� ...... �� �-1 .......... Check # ELEcTRiCAL INSPECTOR 4 ';-, 4 " -) 77MCOMMONRTALTHOF. DEPARTARMOFPUBI BOAROOFFIRE APPLICATTONFOR PERMIT M ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Town of North Andover CO�fficce Use only Permit No. / /f CtYIIZ12:00 � Occupancy & Fees Checked RMELECFRICAL WORK ELECTRICAL CODE, 527 CMR 12:00 Date The undersigned applies for a permit to perform the electrical work described below. Location (Street � Owner or Tenant Owner's Address To the Inspector of Wires: Is this permit in conjunction with a building permit: Purpose of Building Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Yes 1:3 No © (Check Appropriate Box) Utility Authorization No. Overhead ED Underground Overhead 1=1 Underground No. of Meters No. of Meters No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above 1:1Below F1 Generators KVA round , round No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs a No. of Motors fj oL Total HP OTHER- hMM=Cov$age. RO=ttDtheiegttitanalt "a%wbjMG=alLaws IhaveaamailiablkkmuanoePohcyirldx&ECompiceCovetageoritsabswUeWwv at YES ® NO Ibavemb ikdvandp udefsametDthe0ffm YES ffytiubawdrelodYES plea9eir thetypeofcovaageby cllelgthebox INSURANCE BOND MER EVira6m Date FdValueofF7edricalWolk$ WodctoSW . — O 1WecfimDa Begged Rough FRA FIRMNAME S G' ,%G /+lG LicawNo. _1,7Q/ Sigh �%y c LiMWNo %9 1�� BusssTel No. Z'Ze ,C�/Sc' ;,r Alt Tel No. ' OWNER'S INSURANCE WAIVEP,IamawaodAtheLx"medoesnothavaetheinsuranceoc)wworitss<�egtu"4-ulasoptedbyMa%adlusetts CvmalLaws and that my signature on this pwnl application waiNvs this tequaanat (Please check one) Owner ED Agent Telephone No. PERMIT FEE signature of Owner or Agent The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: Location: Cifi+ Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: -- - Address • City' Phone # Insurance Co Policv # Company name - - -- Address City Phone # Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MCL 152 can lead to the imposition of criminal penalties of.a fine up to $1,500.00 and/or one years' imprisonment_as_well_as_civil.penattiesin.theijxm-d aSTOP II.V.ORK ORDFRand_afore_ot_($I. DM)-atlay.igainst.Lhe I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. i ! do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone.# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensina. I] Building Dept Check 0 immediate response is required .0 L.icensin_q Board E] Selectman's Office Contact person: Phone #. E] Health Department — E Other : #I, L cation 0 F4 0. 14 Date 01 40RTFI I TOWN OF NORTH ANDOVER 0 Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ S CHUS Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector -1 k '� Div. Public Works w z Q 5 Q z _ LU u LU z 6 0 z C F m h F a a LU a a z I" i U a. G V) u (� N z O M cn cu E- X �r z _ G O z � Q 3 l F�1 — J W = — F _ Z z IM y w y y p.' n Y Z rW V z :1J (J y y F �xc y rr z z z C �+ 'L y w z z ` ZiaLu - G L.� z 0 U r.. G ¢ - W z Q W z W u \ Q F Z 5 uZJ — C' } LL � y C N � W J 7 C C W C z UJ Q - LL: w z Q 5 Q z _ LU u LU z 6 0 z C F m h F a a LU a a z I" i tiv w VA s? ui om n c� o ,m c a � o � aa� C �2 o O w z vQ. cn Cc: m c p w b O GG v C U C ti(nNm' p" �o 0 C �"� w m 0 G C ¢ C7 � O C W w v p z cn C� x O cn ui om n •. Mlti CD O E O L O V Z co O H � C I CM ca y p 'C y O O �E0co m m ~ = O � CD G O CD L m O a �a o C � cc2 ca C � � ci ca � c CLC � y c� o ,m c o � c O N C vV C C CL O ev � m C G O � Ea c m vl :t v •r n o c E f ! ow C., $ ; c `� CIO M 07 m N _ Co L C H COO C 0m E � m N_ O ' Z = � O co C�m Q,ct m o� N � Z O ca d C m N y C `E3 =H m m06 Q N W C O21�Z Z 0 .O O a.. Z co) O LU O O O COD d O O :6 _ =o�•= O = 0- CL •. Mlti CD O E O L O V Z co O H � C I CM ca y p 'C y O O �E0co m m ~ = O � CD G O CD L m O a �a o C � cc2 ca C � � ci ca � c CLC � y BAY STATE ADJUSTMENT SERVICE 83 Pine Street, Suite 107, Peabody, Mass. 01960 Telephone Numbers (508)535-3334 (800) 865-2206 0b\l a' FAX (508) 535-7106 �&1N A� 9y Town Fire Department On ppR 1 fl Building Commissioner Board of Selectmen •''" Town of North Andover Town of North�And�ve Town Hall Town Hall North Andover, MA 01845 North Andover, 1845 Re: Insured: Charles C. & Linda M. Fucca Property Address: 4 East Water Street No.Andover, MA 01845 Policy No.: HOM8701614 File No.: 6 -913 -ICE Company: EastGuard Insurance Company Date of Loss: 01/10/96 Type of Loss: ICE Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Massachusetts General Law, Chapter 143. Section 6 to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and file number. Paul R. Nestor, Jr. General Adjuster On this date, I caused copies of this notice to be sent to the persons named above, at the addresses indicated by first class mail. ofoaoazat -4 9446"deut -7"Ma w rldj 409 4 iif""da"aU Uoftifvt 741404d 14"Oewz" .4 9dalr 9Kauaa ,ce 4dfu4au iiTe xkz