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Home My WebLink AboutMiscellaneous - 4 SURREY DRIVE 4/30/2018 4 Suaae.� i�w�� 1 BUILDING FILE Commonwealth of Massachusetts Official Use Only o Department of Fire Services Permit No. 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 (PLEASE PRINT IN BW ORTYPEALLINFORMATION) Date: City or Town oh NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant �J� Sp�,j`gP a to Q, Telephone No. Owner's Address J L Is this permit in conjunction with a build g permit? YesA 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 Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA W Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets /0 No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches 41 No.of Gas Burners No.of Detection and Initiating Devices s No.of Ranges No.of Air Cond. Total No.of Alerting Devices Iv Tons No. of Waste Disposers Heat Pump NumberI Tons I KW No.of Self-Contained Totals: ..................... "'......""....... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ CoMunicectionipal El Other nn 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 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: Inspections to be requested in accordance with MEC Rule 10,and upon completion. l?` 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: INSURA=NCE BOND ❑ OTHER ❑ (Specify:) I certify,tinder the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: . 1,4 LIC.NO.: Licensee: Qi '' Signature LIC.NO.: 17Z (If applicable,a er"e mpt"in the It ense na tuber line.) Bus.Tel.NoC��d�ir 3 � Address: 5 e ! ! Alt.Tel.No.: .Per M.G.L c. 147,s.57-61,security work requires Departm ofPublic 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 M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: - �l I Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: a s ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECT ON: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Sig ature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com NORTH 3a°O:"':;':�•h�� TOWN OF NORTH ANDOVER * i ; PERMIT FOR WIRING Ss,��syf� This certifies that .........................`' ... .........................................e ............................................. has permission to perform ...�:S.QcM .... .�Y!. .e ,............................ r C.n wirin/�g in the building of................... ................................................................................... `at ..A.. . L �.... . ......................North Andover,Mass.......................2 ..�............. ......... Fee...1.�, .........Lic.No�o1 ....... h ELE CAL INSPECTOR �I Check# v 12072 U- 1 6"A. 2Iia The Commonwealth of Massachusetts - Department of Industrial Accidents 07 Office of Investigations 600 Washington Street Boston,MA 02111 Uf www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): Address: City/State/Zip"- .r � 0 Oljfjy 3 Phone 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. E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.0I am a sole proprietor or partner- listed on the attached sheet. �• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.El Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.[i Other comp.insurance required.] *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 they ami 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. 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: 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. X do hereby cert under the pains and alties of perjury that the information provided above is true and correct Simature: Date: Phone#: L SCJ 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.EIectrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: - i Information and instructions ' Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance;construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment,be,deemed to bean employer." MGL chapter 152;§25C(6)also states that"every state or local lie-eiisiiig agencyshall 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 producedacceptable 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 r 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 Coxazaoo-meaZth oassachusPtis Department of Jn.dustdal,Accidents Office of Investigations 600 Washington Strect Boston}MA,02111 Tel,#617-727-4900 at 406 or-1-877:MASS-AB& Revised 5-26-05 Fax#617-727-7749 wwwaxxass,g4vfdia a ..r Commonwealth of Mas uset[s Division of Registrati Board of Electri RYAN M E W A' 45 ADA r LAWREN 4 F Master Elec ' 'a 21726-A 07131/2016 q , . SY0..00883 1 5c { License No. Expiration Date. Serial No. y � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY 7H hI'04t1v MA DATE 1 0-7 /S. . PERMIT# 16o JOBSITE ADDRESS �/ �y � �, - OWNER'S NAMEJ S/-1 1Zl4Utvo l . rOWNER ADDRESS TEL S� .ze37s FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL La' PRINT CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO FIXTURES Z FLOOR— BSM 1 1 2 3 4 5 6 7 8 1 9 10 11 12 13 11� tf BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM - DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM i. .. I __ - _ --a I__ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN ' i - -I-- FOOD DISPOSER I = FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) - KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL -- SERVICE 1 MOP SINK l TOILET ' URINAL # - WASHING MACHINE CONNECTION - I - r-- WATER HEATER ALL TYPES WATER PIPING - i OTHER -- _ - . INSURANCE COVERAGE: I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TY 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 by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT d 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 knowled and that all plumbing work and installations performed under the permit issued for this application will be in compliant 11 rtinent r Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME -P'� LIAN t LICENSE#® SIGNATURE Mp0""'Jp❑ CORPORATION❑#COPARTNERSHIP❑#�LLCD# COMPANY NAME ,� i M. ADDRESS1 16 boklAfQ 1' J\ r CITY STATE t' ZIP Q TEL - FAX —�CELL D�6MAIL V) 1 Irl I' ` J plop I I i i 10048 Date . 7/ . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . . / . . .... . . , ... ) . . . . . . . . . . . . . . . . . has permission to perform . .... . . . . . . . . . . . . . . . . . . . . . . . ,�q....,� plumbing in the buildings of. . . .! X./7. . . . . . . . . . . . . . . . . . at . . Fee . Lic. 20.'/51' North Andover, Masso. 7! . . . . . . . . . . . . . . . �t�?'. . . `� ' PLUMBING INSPECTOR Check# V3 I �1 I ;COMMONWEALTH OF MASSiACHUBETTS • r tK LICE( SED AS A MASTER PLUMBER' x ISSUES THE ABOVE LICENSE RaBE�tTO 'FLAIANI 15 DflRIAN DR MA 01835 85D. 4 1471 05/01/11426r4 � -4 The Commomvealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street,,Suite 100 Boston,MA 02114-2017 www mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Roberta Flaiani PH:D Address: 15 Dorian Drive City/State/Zip. Bradford,MA 01835 Phone#: 978-556-5617 Are you an employer?Check the appropriate bog: Type of project(required): 1. ✓ I am 4. 1 am a general.contractor and 1 a employer er uith ❑ mP Y employees(full and/or part-time). have hired the sub-contractors ❑New construction 2.❑ I am a sole proprietor or partner- wed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have S. Q Demolition working for me in any capacity. employees and have workers' o workers' co co insurance.# 9. Q Building addition [N comp.insurance comp. 5. Q We are a corporation and its 10.0 Electrical repairs or additions 3.E1 I am a homeowner doing all work officers have,exercised their I I❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required] t c. 152,§1(4),and we have no 13.0 Other employees.[No workers' comp.insurance required-] *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: Macdonald&Pangione Insurance Policy#or Self-ins.Lic.#: 08 IUEC VT7745 Expiration Date: 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. Ido hereby c . and and enahies oer u that theinformation provided above is true and correc- Si tore: . _ _.. Date : Phone#: 978-556-5617 Official use only. Do not write in this area,to be completed.by door 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#•