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HomeMy WebLinkAboutMiscellaneous - 4 High Street Suite 175 MVLC�� �� a v :sem y z� �\� a a� -� ¥ :w_ \\� �� «� y� A ¢� R: 11316 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ........ ... /- . Al ... ..... ..... .. ...... has permission to perform ....... ............. . . . ........ plumbing in the buildings of .... #Zf.// ..... :T;�� ....................................... at................. I ...................................................... Fee.50 . . .... Lic. No . ..................... Check# —q-9 4'- F--7- -- ..., North Andover, Mass. ......................................... PLUMBING INSPECTOR J* 3a r ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK POWNER TYPE OR PRINT CLEARLY CITY , �a�z /�y u U ! MA DATE PERMIT # JOBSITE ADDRESS OWNER'S NAME ADDRESS TEL FAX OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL D RESIDENTIAL NEW: Or RENOVATION: © REPLACEMENT: Q PLANS SUBMITTED: YES Q NOD FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM _ ._. DEDICATED GREASE SYSTEM 1 _._____I ______! _i ._........... .P DEDICATED GRAY WATER SYSTEM i (�_. ( J ___.. I DEDICATED WATER RECYCLE SYSTEM I } .._ I _—.I -..— _ ! _..__I DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER ------- _._-P FLOOR/AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SeRVICE / MOP SINK TOILET WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER ,Srwcr �_�A -1,c?v� INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES n1NO Ell IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY — OTHER TYPE OF INDEMNITY Q BOND PI 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 Q AGENT �Q 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 k ledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wall rti ent isio oft e (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ PLUMBER'S NAME _.. �T„--_� _z�► LICENSE # ? IGNA URE (VIP Q' JP Q CORPORATION �# G _I PARTNERSHIP D# LLC COMPANY NAME .t q n /h e-4 liq--1 t ;OADDRESS /✓ __ _ CITY �.,��-..._.._.._I STATE •C/l' ZIP I O ��� �k TEL FAX a�j CELL EMAILCin 6T �_snc Wit_/ cam%' o rl z N ❑ Lij w N The Commonwealth of Massachusetts Department of Industrial Accidents M Mr. X Congress Street, Suite 100 _Boston, MA. 02114-2017 www.mass.gov/dia ° w sas Workers, Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plum ers. TO BE FILED WITH THE PERMUTING AUTHORITY- A ' licant lnzorInauuu ,(� 1 < .,cG Name (Business/Oiganizationfindividual): /1l�lc b %�� /fL C/ Address: All City/State/Zip: /ef r► 4 Phone #: � �.. Are you an employer? Check th��e++appropriate box: Type of project (required): %. [��ew construction 1.Q I am a employer with Cd employees (fall and/or part-time). for in $, E] Remodeling 2. ❑I am a sole proprietor or partnership and have no employees working me comp. insurance required.] 9. ❑ Demolition any capacity. [Noworkers' 3.❑ I am a homeowner doing all work myself,. [No workers' comp. insurance required] t 10E] Building addition 40 I am a homeowner and will be hiring contractors to conduct all work on my property. I will insurance or are sole 11.❑ Electrical repairs or additions ensure that all contracto1 J,rs either have workers' compensation 12_O plumbiztg repairs or additions U Yl proprietors with no employees. 5.F1 I am a general contracto Iand I have hired the sub -contractors listed on the attached sheet. comp. insurance. 13�. 0 Ro6f repairs These sub -contractors have employees and have workers' 14.0 Other 6. ❑ We are a corporation and its, officers,have exercised their right of exemption per MGL c. comp. insurance required.] 152 §1(4) andwe have no employdes. [No workers' *Any applicant that checks bbk #1 must also fill out the section below showing their workers' compensation policy information Homeowners who submit this affidavit indicating they are doing all work andthen hire outside contractors must submit a new affidavit indicating such I Contractors that check this box must vit indicatched ing 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. .- X am an employer that is providing -workers I compensation insurancefor my employees. Below is the policy and job site information. ` Insurance Company Name:�r�' `'Gy Zoe g���5-.S Expiration Date: /0 pc3/�lS� Policy # or Self -ins. Lie. #: �� �� Job Site Address: City/State/Zip Attach a copy of the yyoxkers' compensation policy declaration page (showing the policy number and expiration date). olation Failure to secure coverage as required us civil penalties in?the form ofa25A is a S`Z'OPnal iWORK ORDERIand fine of p to $250.00 a and/or one-year imprisonment, as well a p day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. X do hereby certify under the pains and penalties ofperjury tliat the information provided above is true and correct. Date: Signature: official use only. Do not write in this area, to be completed by city or town offzciaL Permit/License # City or Town: Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone #:. Contact Person: 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 hize, express or implied, oral or written." An employer is defuied as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enferprise, 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 xequiired." 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 (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 Iudustrial 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 thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 9 Date -67 ............ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING '-s This certifies that ............ . .. . has permission to performo ....... n ....... plumbin ............... ,g in tif buildinglol .... U��JNVAA$ ............................. at.. North Andover, Mass. ....... S>. �--- ............................ Fee33.4 -0 Lic. No. �?33 ...... ...................... .......................................................... ............ PLUMBING INSPECTOR Check —9-11— �P� s�-�s.�51�bs Nl�- 'wi 1104.2 Date.st/,/ 1Z\5 . ........ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that....::::::.:T— ...................................................................... has permission to perform ........ ...... 5ok,?k ........................................... plumbingin the buildings of ............................................................................................. at.4.1 .... 1.7.r . ............. r . ................. /North Andover, Mass. Fee/ /Y.z ... Lic. No. ArZ 7— --MiP . E . C . T . 0 . R .................... L:U Check # (7 LYUMBIN 4+ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK b POWNER TYPE OR PRINT CLEARLY CITY 'UUrfg 41V,00Ve1, MA DATE 311dZ15 PERMIT# JOBSITE ADDRESS i 16-K S V ► fe. 17 5 . OWNER'S NAME G' C ADDRESS Q1 T -VA 1d 0 5f 0(-7(0 11 t`TEL FAX OCCUPANCY TYPE COMMERCIAL Do EDUCATIONAL ❑ RESIDENTIAL ❑ NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NOR] FIXTURES'l FLOOR-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESE] NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required bj 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Ti r i 6 t2Ff J✓E LICENSE SIGNATURE MP ® JP ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑l # COMPANY NAME LJAMQ S f�r✓� �� ADDRESS 7,-, el?Z,") CITY �A �e STATE •N� ZIP 0307) -TEL FAX CELL9Z 9 5%23 EMAIL Oa `-i Cd,-�c 5-""/ 3p��an[���� (CW7,"1 V M 00 1U. Date ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ . ... .... ...... ... .. ..... . ........ has perniission to perfonn ..... —.�e..,P-4 ......... -V�� .... ......... .... ....... ..... ............... \ ..... .................................. wiringin the building of ......................... ..................................................................................... -15 vA at ..... I ................. �N --Andover, Mass. �4 Fee....... . ........ Lic. No . ................. .... ...... hL'E*C*M-* . . .... .... % 6 - i � o\ IZ11 to I'l W J Commonwealth of Massachusetts Official Use Only a Department of Fire Services Permit No. IJ b Occupancy and Fee Checked , BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07j (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: I'C'J ! City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of nhis or her intention o perform the electrical work described below. Location (Street & Number) Lf' h ��1 0" V,- �Ze Ax (7, Owner or Tenant /17 `/� OJ, Telephone No. Owner's Address Is this permit in conjunction with a building ermit? Yes No ❑ (Check Appropriate Box) Purpose of Building !r1 o�9 � 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: Completion of thefollowing 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- El 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 Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number TonsKW ..... ..... " No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers 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 E uivalent OTHER: rD Attach additional detail if desired or as required by the Inspector of Wires. Estimated Value of Electric4l Work: (When required by municipal policy.) Work to Start: / - e Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO RAGE: 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 tlzepains andpenalties of eriury, that thein rnZation on this application is true and complete. FIRM NAME:. 61 /fI "� LIC. NO.6-1: Licensee: G Signature LIC. NO.: (If applicable, enter "exempt" in the lice stuber line. / Bus. Tel. No.: Address: &1(0 �% 7,!J ® Alt. 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/Agent PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the o notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed:** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: w Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M X,Failed Re- Inspection Required ($.) ❑ 5 Inspectors Comments: } Inspectors Signature: Date: FINAL INSP "CATION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: G /1 DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com 2 �► The Commonwealth of Massachusetts Department ofIndustrigl Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ut www massgov/dia 'workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual):. Address:G��/V% City/State/Zip: /�/D/jGf, j� _121A� Phone #: p ��� �( o Are you an employer? Check the appropriate box: Type of project (required): 1. I am a employer with / 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet.1 7• ❑ Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition workingfor me in an capacity. Y p t5'• workers' comp. insurance. ` 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] i employees. [No workers' 13. n'Other comp. insurance required.] *Any applicant that checks box 01 must also fill out the section below showing their workers' compensation policy information. 'Homeowners who submit this affidavit indicating they lice 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 anti job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: 1�7 (' 7/ O City/State/Zip: /1/ l 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 maybe forwarded to the Office of -Aivestigations of the DTA for insurance coverage verification. ,[do hereby certify under the and pen ies ofperjury that the information provided above is true and correct. Sienaiure: /I Date: 617 07 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 #: 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 employes, 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 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 -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 maybe 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 filled out each year. where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The 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 Mossachusetts Department of Industrial Accidents Office of Investigations 644 Washington Street Boston., MA. 02111 TeX. # 617-72.7-4900 ext. 406 or 1-877,MASSAFE Revised 5-26-05 Fax # 617-727-7749 www-Mass,govaa r Date. �// TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that i� L . ............................................................ has pen-nission to perform ....... ,fve.z�� ... le� ....... �2.k.,z .... ..... wiring in the building of ............. A 4 ;4 .... .... ........................................................................... at A / 75' — /" v4L C- ................................... .... . I North Andover, Ma 0 Fee.A?I� ..... Lic. No. Check # 7 . ................. .. .. ........... iN�P�q, , IECTRI AL �INSPE IV MME 0100 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 1325 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: V,2 AZ/S City or Town of. NORTH ANDOVER To theIn pe or of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) y ' Z � //��/ 75 Owner or Tenant I 1(/t rL� Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ;9 No ❑ (Check Appropriate Box) 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 Nature of Proposed Electrical Work: f � �2 a rk ��J.lJ�_ —11, Completion ofthe followinc table may be waived by the Insvector 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- E] rnd. rnd. No. 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 Devices No, of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: " IKW ' ""'"'""""' No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ 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 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 97res. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start:_COVERAGE: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO ERAGE: 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 0 BOND ❑ OTHER ❑ (Specify:) Icertify, under the pains andpenalties o perjury, that the information on this application is true and complete. FIRM NAME:.`` LIC. NO.: //%%d It Licensee: 5 Signatu LIC. NO.: (If applicable, ent r "e mp " in the license nu ber line. Bus. Tel. No.�� 3Z Address: : l"IAA�� Ge 4 /7! '.�'! }� � /_R Alt. 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/Agent PERMIT FEE. $ ��— Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the.provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ r. Inspectors Comments: • Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: PassM Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass IN Failed Re- Inspection Required ($.) ❑ ri Inspectors Comments: Inspectors Signature: Date: FINAL INSPE ION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: A 44 Inspectors Signature: a&Lrl Date: 6 16 IS - DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 - www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: ----5 City/State/Zip: Are you an employer? Check the appropriate box: Phone #: �7,F 1. ❑ I am a employer with employees (full and/or part-time).* 2. I am a sole proprietor or partnership 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 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. ❑ 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): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other *Any applicant that checks box #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. $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 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: City/State/Zip: iy�� I'A44 c Gv�✓ Q�fJ�p,� Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). 7 Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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 N day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance 1i coveraize verification. I do hereby certify un a pai pen ties perjury that the information provided above is true and correct. Si nature: Date: L'�—�S �F7 Ste^ -7 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 #: 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 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 (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 cityor 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 L 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 (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.` The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia I