HomeMy WebLinkAboutMiscellaneous - 431 BEAR HILL ROAD 4/30/2018 431 BEAR HILL ROAD
210/064.=10000.0 \
Date......��...� ..Ar.............
OF NORT{�,h
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
C gs�cHUS�
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This certifies that ..... .... ... .... /..../...........................................................
f ,has permission for gas installation .........Se
n the buildings ofd.j.....IU
. ...................................................................................
at... � �.... !'.r!1.�1... ............................. ...... No Andover, Mass.
Fee'?? -.k... Lic. No..30c1.. ........ ..... . ......................................................
GA It PECTOR
Check#�
Date,.. .. :.1.��. .........................
�r►ORTh
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
,sSACHUSfc
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Thiscertifies that ............................................................ ......................................................
has permission for gas installation .. t .. ......................................................
in the buildings f.... .................. .
at.....`t"-�..�....... ...... .2`- �. .. ..�`' -.........., North Andover, Mass.
Fee.3.1......... Lic. No. .�7' .Pcl.. .......
.....................................................................
GASINSPECTOR
Check#
i
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING'WORK
CITY _NO ANDOVER MA DATE 10130/15 - �PERMIT#
JOBSITE ADDRESS 431 BEARHILL ROAD OWNER'S NAME I BEN
GOWNER ADDRESS I SAME j TEL 978 689 4444 FAX NH/A
TYPE OR OCCUPANCYTYPE COMMERCIALD EDUCATIONALRESIDENTIALD
PRINT Q
CLEARLY NEW: RENOVATION:D REPLACEMENT:E] PLANS SUBMITTED: YES[] N0F1
APPLIANCES Z FLOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
� I
BOOSTER
CONVERSION BURNER
__j k F
COOK STOVE
DIRECT VENT HEATER '
DRYER l
_ _ .
FIREPLACE -
FRYOLATG _
FURNACE
GENERATOR -
GRILLE -�` k - -- I �1`
INFRARED HEATER a - - - - - --
LABORATORY COCKS M _P - fI-
MAKEUPAIRUNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT k 1, f - f _'
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER - _
OTHER I UG GAS LINE...
p _ I k _ fi
-771
INSURANCE COVERAGE
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [D OTHER TYPE INDEMNITY E] 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.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER [] AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true ccurate to the st of y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co lance th all Pe ti nt prov' ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1-2
PLUMBER-GASFITTER NAME' . _ �l�l LICENSE#[CO? I GW URE
MP[ MGF D JP El JGFn LPGI PARTNERSH [[ 4I LLC D#[
COMPANY NAME: HOLDEN OIL INC. _ ADDRESS 91 LYNNFIELD STREET
CITY PEABODY _ _ STATEMA ZIP 01960 - - TEL 978-531-2984
i EMAIL MARKL@HOLDENOIL.COM
FAX 978 5314321 CELLr y `
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The Commonwealth of Massachusetts
` Department of Industrial Accidents
Office of Investigations
kv I Congress Street, Suite 100
Boston, MA 02114-2017
www mass govldia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): HOLDEN OIL INC
Address:91 LYNNFIELD STREET
City/State/Zip: PEABODY MA 01960 Phone#:(978)531-2984
Are you an employer? Check the appropriate box: Type of project(required):
1.0 I am a employer with 45 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. [] Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp, insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their l l.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL l2.❑Roof repairs
insurance required.] t c. 152,§1(4),and we have no GAS FITTING
employees. [No workers' 13.0 Other
comp. insurance required.]
'Any applicant that checks box 91 must also fill out die 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 emplmyees Below is the policy and job site
information.
Insurance Company Name:HDI GERLING AMERICA INSURANCE CO.
Policy#or Self-ins. Lic. #:EWGCD000014514 Expiration Date: 12/31/2015
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(shoeing 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 hereby certify under the pains and pen hies of perjury that the information provided above is true and correct
Si ature: ' -
Dat e:
Phone#: 9785312984
Official use only. Do not write in this area,to be completed by city or town official.
Cih,or Town: Permit/License#
Issuing Authorih'(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing inspector
6.Other
Contact Person: Phone#:
V.COMMONWEALTH OF MASSACHUSETTS::.. ,
o-r .
- -.-BOARD OF,
PLUMBERS ,A`N'0 QASF I.TTERS,:i a
ISSUES THE FOLLOWING':LICENSE y
LICENSED AS AN LP .GAS INSTALLE
is
J.EF.FREY J PASZKOWSKI
286 NE
W.BURY STREET W i
LOT. 97:
P:EABODY M`A 01960 74 1
3096 a5/ol/1.6, 215145
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' North Andover MIMAP November 3, J15
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I Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83,
—SR Meters Data Sources:The data for this map was produced by Merrimack
Roads t NORT1l 4 Valley Planning Commission(MVPC)using data provided by the Town of
O siva° r� ti North Andover.Additional data provided by the Executive Office of
17,Easements �< <e 0� Environmental AffairslMassGIS.The information depicted on this map is
Parcels 9 for planning purposes only.It may not be adequate for legal boundary
defnition or regulatory interpretation.THE TOWN OF NORTH ANDOVER
MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
X w THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY
OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
THIS INFORMATION
1SSACM113
1"=41 ft .�.
Date.......L.......2........................
OF NORTH
TOWN OF NORTH ANDOVER
o % PERMIT FOR WIRING
BS�cMus�
Thiscertifies that .... .............�... .C!.?.:..........................................................................
has permission to perform ..:�.:.� /f lJ e
..................G./...�.......................1............................
wiring in the building of............�
.................................................................
f;N.�...!.�'..:.!l i !C%t orfh Andover,Mass.
at ....... ......../ .. .................................,
Q�Z
Fee.//.O......-...........Lic.No. ................. .....411J�: ---
....... ............
ELECTRICAL INSPECTOR
Check# ��
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
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) FORMATION) Date: 9 - 2, 3 - J
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) Itt.l-1, Wzz
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? YeL.P?D No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
- Existing Service Amps / 0 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: 6ti t
lei
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
No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency ig ting
rnd. rnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No,of Alerting Devices
Tons
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: '"'' ' " " ' "'"'"" " ..................... Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or E uivalent
No.of Water KW No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify,under thepains andpen``alties of perjury,that the information on this application is true and complete.
FIRM NAME: _6-b 2 LIC.NO.:
Y Licensee: �� Signatur lv ---� LIC.NO.:
(If applica le,enter t"exem t�n the licens nat ber h .) Bus.Tel.No.-
Address: / Alt.Tel.
*Per M.G.L c. 147,s.57-61,security work requires0bepaitment 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 •t
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 1
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 0 Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass N Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date: •
PARTIAL ROUGH INSPECTION:
Pass F?] Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
ROUGH INSPECTION:
Pass[d Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
FINAL INSP TION:
Pass IN Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
=: F Boston,MA.02114-2017
www.mass.gov/dia
Workers'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTMG AUTHORITY.
Please Print Le 'bl
A licant Information y
Name(Business/Orgabization/Individual):
L✓
Address: % �,/,� , l�
•�.1 U S Phone#: ��
City/State/Zip: 1 P' �' x. .
Are you an employer?Check the appropriate box: Type of project(recluired):
1. 1 am a employer with employees(full and/or part-time).* 7. ❑N6Vd6nstr6dl0n
2.N am a sole proprietor or partnership and have no employees Working for me in 8. �Remo delliig
any capacity.[No workers'comp.insurance required] 9. EJDemolition
3.E]I am a homeowner doing all work myself(No workers'comp.insurance required.]t 10❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
11.0 Electrical repairs or additions
ensure that all contractors either have workers'compensation insurance or are sole
proprietors with no employees. 12TQ P1ulnb]ng repairs Or additions
5,❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13•. R66f repair's
These sub-contractors have employees and have workers'comp.insurance.t 14. Other
6.❑We are a corporatiori 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.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who subI .1.his 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 attach d'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.
lam an employer that is providingworkers'compensation insurance for my employees. Pelow is the policy and job site
information.
Insurance Company Name-
Expiration Date:
Policy#or Self-ins.Lic.#:
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 requited under MGL e.152,§25A is a criminal violation punishable by a fine up to$1,500.00
vil penalties in the form of a STOP WORD ORDER and a fine of up to $250.00 a
and/or one-year imprisonment,as well as ci
ay be forwarded to the Office of Investigations of the DIA for insurance
day against the violator.A copy of this statement m
coverage verification.
I do hereby cerci nder tliepains andp alti perjury that the information provided above is true and cc rrect.
- 'Al G Date: ✓ �J j�
Si ature:
Phone#:
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):
LI.Boardealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
on: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their em' loyees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of We,
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
ofthe foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver'or trustee ofan 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 ba deemed to be an employer."
MGL chapter 1.52,§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 certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple 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-MASSAFE
Fax#617-727-7749
Revised 02-23-15 wwwmass.gov/dia
i -
i
�I
t T COMMONWEALTH OF MA$SAOHUSETTS.
'p o • • C
ELEGxRIC AN
ISSUES THE FQL"LOWING L.I CENSE 'AS
REG I STERt!) MASTER E�LECTR;I C I A�J�
w i
ED>WA.RD G HAJJAR
1200 SALEM 5T s
..NORTH ' ANDOVER .MA 01845 4924
.. 16 27351
636g, A.: :07/31
: : - - _- -----�
�f COMMONWEALTH OF MASSACHUSE... I
EL�1;T�R 1 C1 AN,�
ISSUES THE FOLLOWII�:G LICENSE .
AS A R.EG :1OURNEYMAN ELECTR"I,CI,A� t¢ �
E D.W. .A:R!.b G HAJJAR
1200 SALE M<
pW
NORTH ANDOVER :MA 01.845 4924
17982 E . 07/33%16 27350 t
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To DATE TIME A
PM
FROM
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(PHONED
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Date . .,. .-. 1 . . . . . .
TOWN OF NORTH ANDOVER
r y
PERMIT FOR WIRING
3't�4i A
This certifies that . 41 ... ". . . . .�. .
i ,
has permission to perform .
wiring in the building of 4.5
at . .
. . . . . ?`t.!� . ./ .�� . . �G /-North Andover, Mass'
i
Fee
ELECTRICAL INSPECTOR
Check# A
11117
a Commonwealth o f Massacicu Hi Official Use Only
2epartment ol.}ire Jervicei Permit No. lf`
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1%07] (leave blank)
t`
" 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: 9' /,W/x
City or Town of: M ff h ,/4+700Ve,(--' To the Inspector of Wires:
r� By this application the undersigned gives.notice of his or her intention to perfo the electrical work described below.
' 3 / Oear
Location(Street&Number) ,J/ r
Owner or Tenant v /" B ec&0Telephone No.
Owner's Address M 6
Is this permit in conjunction with a building permit? Yes ❑ No � (Check Appropriate Box)
Purpose of Building 11C44'honeJ H Pa�_ Utility Authorization No.
1
Existing Service � Amps j 70/Z10 Volts Overhead ❑ Und rd j
g � No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: See/1
Completion of the ollowin table may be waived by the Inspector of Wires
No.of Recessed Luminaires No.of Cell.Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
•+ No.of Luminaires Swimming Pool Above E] In- ❑ o.of Emergency Lighting
rnd. grnd. BatteEy Units
No,of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No,of Zones
No.of Switches No.of Gas Burners o.of Detection an
Initiating Devices
No.of Rangeso
No.of Air Cond. No,of AlertingDevices
-Tonsns
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: """'"""""""""""""""".............. Detection/Alertin2 Devices
No.of Dishwashers Space/Area Heating KW G 000 LocalMunicipal
❑ Connection ❑ Other
No,of Dryers Heating Appliances K`,i, Security Systems:*
5. No.of Devices or Equivalent
No.of Water No.of No.of
KW Data Wiring:
Heaters Signs Ballasts No.of Dvices or Equivalent
No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: QG� (When required by municipal policy.)
a Work to Start: I Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:)
I certify, under the ains and penalties of perjury,that the information.on this application is true and complete.
FIRM NAME: R. ledr)1 _ LIC.NO.: 203/2
Licensee:dire,",* Signature �T /� LIC.NO.: 10114;-e
(If applicable en er " xempt"in thq7cense number,line.) Bus.Tel.No.: G !7- 9 S7-Z y /
Address: - Get�� ,� �' �SrnPhG./� 02/�
Alt.Tel.No.:
h *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
s required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $ (J
r
Commonwealth of Massachusetts Official Use Only
i� d I
\ Department of Fire Services Permit No.
'\ Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1107]
(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: `7 — 31— r Com•
City or Town of: NORTH ANDOVER To the lnspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) 3
Owner or Tenant 37 8•(- n�Y—\ T Telephone No.917y ,$''elf LAS
Owner's Address -
Is this permit in conjunction with a building permit? Yes No ❑ (Cluck Appropriate Box) 067 - 73
Purpose of Building jam, - Utility Authorization�No.
- Existing Service, ®e- Amps 10eG Y-Q Volts Overhead El Undgrdj�r No.of Meters !
n-Prhi-nd Undgrd ❑ No.of Meters
.. Date . .7-3 &7 1—t5
TOWN OF NORTH ANDOVER bl ay be waived by the In "ctor of Wires.
o.of Total
PERMIT FOR WIRING ransformers KVA
� w
enerators KVA
o.o mergency Lighting
This certifies that . atter Units
c 4
,. .�, .CC -I
has permission to perform . . . r. . . . . . • • • • • • IRE ALARMS No. of Zones
�,7 No.of Detection and
wiring in the building of . . . . -,- J Initiatin Devices
at . . // -`�. . . ' ' ' ' • ' ' • • • • • • • • • . . . . No.of Alerting Devices
YS/ /S '/`- f� r. b• , North Andover, Mass. No.Detof Self-ContainAlerting ed
vices
Fee .
� } Lic. No. • •(�97� ,'7 Local[I Connection
[:] Other
' � Connection
ELE TRICAL INSPECTORSecurity Systems:'
C, eck # 7
No.of Devices or Equivalent
Data Wiring:
No.of Devices or Equivalent
Telecommunications Wiring:
10985 No.of Devices or E uivalent
esired, 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 COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify,under the n penalties of e jury,that.the info. t, n on tl 's pplic tion is true and cbmplete.
FIRM NAME: _ �" 1. LIC.NO.: 2-
Licensee: �� l i Signature LIC.NO.:
(If applicable,ent "e�xer�t"in a li a number lin .) r.� Bus.S-2 a - -
Address: (. f , 71 M Alt. o.-
(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.
r '
Town of North Andover 01845
R.E. Basement Remodel at 431 Bear hill rd.
Phill Cargylle was pulled from the job after upgrading the Elecrical work without
Consulting the general contractor or the homeowner as to the scope of the
Upgrade, Wich lead to a$1000 in upgrades and his dismissal.
John Morrissey Remodeling
John Morrissey 9/24/12
Date . .7-3
. 5�'f'SLeU rCya' .
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that . . .(f!.M �,���?�. -t•L•L• •��•,• •
has permission to perform . . . . • • • • • • • • • • • • • •
wiring in the building of . . . . . . . . . . . . . . . . . . . . . . . . . . . .
at Illi.,/ A b• • • . ,North Andover, Mass.
Fee .`.77ti.eje Lic. No. . .� 9� 3f'�' . . . . . �INSPECTOR/
ELE TRICAL
Check# 3 2 c9
77
1100/ 85 �'C<�t�� 4P t
� � �
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
lug
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank Occupancy and Fee Checked
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 INK OR TYPE ALL INFORMATION) Date: —7 ( 2—,
City or Town of: NORTH ANDOVER To the Inspector of Wires:
J 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 8 e, ,�/N Telephone No.777 ,elf LAS
\\ V
Owner's Address
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) 0167 - 73
Purpose of Building &a/P,�,r �' Utility Authorization No.
- Existing ServiceZ ql-- Amps �.G/?,Y- Volts Overhead 0 Undgrd'[�r 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 followingtabl ay be waived by the Ins ctor of Wires.
1 No.of Recessed Luminaires No.of Ceil: TransSusp.(Paddle)Fans Total
j� Trsformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above EiN—o.—OTEmergency Lighting
rnd. rnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones
No.of Switches 'y No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
g Tons
No.of Waste Dis posers Heat Pump Number Tons KW No.of Self-Contained
p Totals: Detection/Alerting Devices
No.of Dishwashers S ace/Area Heating KW Local❑ Municipal E] other
p g Connection
No.of Dryers Heating Appliances KW Sectio.of Devices or Equivalent
No.of Water No.of No.of Data Wiring:
Heaters KW Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP IUTel—eommunicationsNo.of Devices or E u valent
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 COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify,itnder the n penalties of ury,tha the in ormati n on t 's pplic tion is true and complete. /�
FIRM NAME: , 19 ' LIC.NO.: 7-/ A
Licensee: �j js Signature LIC.NO.:
(If applicable,entc " xej in tjze li a number linty.) /ln n/� Bus.
Address: U f fS /� , i ► Y 1�1 Alt.Te. o.•
*Per M.G.L c. 147,s.57-61,security workrequires 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.
J
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organizatiordlndividual):
Address:
City/State/Zip: 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. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I 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.❑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'
comp.insurance required.] 13T] 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.
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 workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
R
Jo')Site Address: City/State/Zip:
At 4),_ 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 Flo hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: 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#:
P�
P
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 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 Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 5-26-05
www.mass,gov/dia