HomeMy WebLinkAboutMiscellaneous - 448 BOXFORD STREET 4/30/2018 (2) / 448D STREET
J 210/105.C-005.0-00 48-0000.0
_ l
Date.. ........................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
HUS
Et
This certifies that ........ ......................................
has permission to perform-.;-e�
-.- � //" (1-7 1// ............
wiringin the building of...................................................................................
..... ............. North Andover,Mass.
Fee.y�............. Lic.No.0...44.... ?................ . . . ..... .. ... .
LECTRICAL INSPECT
Check #
9061
4� L Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. % �-
� r
BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked
[Rev. 1/07] (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrica]Code( EC), 27 CMR 12.00
(PLEA SE PRINT IN INK OR TYPE ALL INFORMATION) Date: /p Ods 0 `j
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her inte tion to perform the electrical work described below.
Location(Street&Number) y �,,, 30 C)e7Owner or Tenant 7/ecx e- �,`�,� e Telephone No.
Owner's Address ,S 6L M (32&,574-29 93 y
Is this permit in conjunction with a buil ng permit? Yes ® No
New
� / El (Check Appropriate Box)
Purpose of Building {may S r Or",
a h Utili Authorization No. 76 °� _ �«2 J/7
Existing Service /00 Amps j,ZO /2 y p Volts Overhead Undgrd❑ No,of Meters J
New Service 200 Amps l.t o /,2-140 Volts Overhead Undgrd ❑ No.of Meters I
Number of Feeders and.Ampacity IOU
Location and Nature of Proposed Electrical Work: 2 0 ,
0 C� atq �+ J r trl S P J�i r P J r Gt r �t�
fu/ was ScrJcc �a,'sF Servtc. �r
Completion o the followin table may be waived b the Ins ector 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 PoolAbove ❑ In- E] o.o mergency ►g g
d• d. Bae 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
No,of Ranges No.of Air Cond. Total Initiating Devices
Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump Number.Tons KW No.of Self-Contained
Totals. Detection/Alertin Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal
Connection Other
No.of Dryers Heating Appliances KW Security Systems:*
No.of water No.of No.of Devices or Equivalent
Heaters KW No.of Data Wiring:
Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.
of Motors Total HP Telecommunications Wiring:
OTHER:
No.of Devices
or E uivalent
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of ectri•al Work:j� /c1 f�t1. C)p (When required by municipal policy.)
Work to Start: p� p Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE CO RAGE: Unless waived by the owner,noe
p rmit for the performance
the licensee provides proof of liability insurance incl p ance of electrical work may issue unless
ty including completed operation"coverage era a or its substantial
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing officeuivalent The
CHECK ONE: INSURAN
CE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify,under thepains andpenalties of erjury,that the information on this ap ication is true and complete.
FIRM NAME: .Z od.,ct LC 0,C 1-r., j L L e
LIC.N
Licensee: c
c
-� � T�� <� Signature „Cer LIC.NO.:
6P 3-
(If applicable, ter "exempt"in the license numb e�ne.) j
Address: (, /�ox S'qZ .�J��►s l�+ c �,, G1 fy� � Bus.TeL No. 9 /S"��.3i
*Per M.G.L c. 147,s. 57-61,security work requires Department--------- c Safety"- License: Alt.Tel No 221�No 7
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 El owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $ =v
,�
� ,
1
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
s � Ogee of Investigations
600 Washington Street
'Milt hinb
'`u' a�� Boston, NSA 02111
t ' www.nzass.gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A licant Information
Please Print LeQibl
Name(Business/ptganization/Individual): Z-,4 d ck k ^' "k C Ac
Address: ?10 , 194
SUCAO 01,P-J 9
City/State/Zip: a�s a�� f��- cePhone#:_. (9'�rF , Rs— —*31 7
Are you an employer?Check the appropriate box:
1.❑ I am a employer with 4, Type of project(required):
❑ 1 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.t 7. []Remodeling
ship and have no employees These subcontractors have 8. Q Demoiition
working for me.in any capacity, workers' comp.insurance. g, M Building addition
[No workers'comp. insurance 5.M We are a corporation and.its
required.) officers have exercised teir 10.7 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No•workers'comp. c. 1.52, §1(4),and we have no
insurance required.]t employees. [No workers' 12.❑Roof
iepairs comp. insurance required_] 13_n Amer
"Any applicant that checks bo>`#I 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 Mile of the sub•cotitractm and their work='comp.policy information.
I am an employer that is.provIworkers compensation insurance for my employees: Below is the policy andjob site
information, J
Insurance Company Name: ' ZtS
Policy#or Self-ins.Lie.#:
Expiration Date:
Job Site Address: City/State/Zip:
Attach a co of the a worke
rs
compensation nsafion policy P po y declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL e. 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 Offs
Investigations of the DIA for i Office of
insurance cove
to v �ficati
ge an.
I do hereby certify and r the pat and pen ry that the information provided above is tri and correct
Si tore: Date: /D (QJ- (�
Phone#:
Er "4 useonly, Do not write in this area,to be completed by city or town officio[
n: Permit/License#
hority(circlie one):Hearth 2.Buildi'a Deg partment 3.Ci /Towt3' n Clerk 4. Eiectri cal Inspector - Plnmbm Ins or
g P�son:
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 timstee 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 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,nottthe Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
eoMpensation policy,please call the Department at the numberlisted below. Self-insured companies should enter their
self-insuranc'e'Iieense 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%gill 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 futum 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 bum leaves etc.)said person is NOT required to complete this affidavit
The Office of Investiptions 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 p
600 Washington Street
Boston, MA 02111
Tel.#617-727-4900 ext 406 or 1-8.77-MASSAFE
Fax#617-727-7744
Revised 5-26-05
www.mass.gov/dia
i
Date..T..^...1.....a. •
. ....
t
NOR71�
TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
,SSACHUSE�
This certifies that .. . .... v. .. �+ f..
has permission to perform 3--,0 . '~`,
wiring in the building of.../
at... ... ' `J�i .............. .North Andover,Mass.
t Fee... ......... Lic.No.:�d.,.S. .Z..C .....
•ELECT CAL INSPECTOR
Check
8865
C,omrnonweaith o� a36achu�a Official Use Only
cx�
�7 Permit No.
2-parlin¢nf a�-}ire�¢rvite9
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/67j aveblank
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 PR.IWT.ININK OR TYPE ALL INFORMATION) Date: 7-/ -pF
Cityor Town of: K),Ak"v.e.K— 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) K(l 9- 41�p xicp � !9�_
Owner or Tenant '"t--G!4 p (_ Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps 1 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: yz-(4 p
..
Com letion o the ollowin table may be waived b the Ins for o Wires.
No.of Recessed Luminaires- No.of Ceil.-Sus .. addle Fans o:of Total-
No.
Transformers 'VA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming-Pool bove ❑ In- ❑ No.of Emergency LAghting
d. gmdL Batteg Units
No.of Receptacle Outlets No.of OR Burners FIRE ALARMS No.of Zones
of Detection an
No.of Switches No.of Gas Banners o.Initiating Devices
No.of.Ranges No.of Air Cond. Tons No,of Alerting Devices
No.of Waste Disposers eat um p: umber I To—as iKW o.of SeIPContained
Totals: Detection/AlertingDevices
No.of DishwashersSpacelArea Heating KW Local❑ unicipa El Other
Connection
No.of Dryers Heating Appliances KW Security Systems:
No.of Devices or Equivalent
" o.of Water KW o.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.HTelecommunications Wiring:
Bathtubs No.of Motors Total HP No.of Devices or Equivalent
OTHER: ..
Qy p Attach additional detail if desired,or as required by the Inspeci 7r of Wires.
Estimated Value of Electrical Work: )goo (When required by municipal policy.)
Work to Start7 s7- 09 Inspections to be requested in accordance with MEC Rule 10,and upon completit n.
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:)
1 certify,under the pains jd penalties o p, ury,that the informadon on this application is true turd complete
FI M NAME: ri(� Y' 5 -t 0--g C11 C .n-a t , LIC.NO.: _
Licensee: - Signature LIC.NO.:
(Ifapplicable enter"exe t"in the license number lin ) Bus.Tel.No.,.>-V--VY f O:Y"d r—
Address: 7-o a Alt.TeL No.:W 7 7 FQ6/t+C--'
*Per MG-L.c.147,s.57-61,sec nity work requires Deparfment of Public Safety"S" use: Lic.No.
OWNER'S INSURANCE WAI VER. I arra aware that the Licensee does not have the liability insurance coverage normally
required by law.. By my signatur,below,I hereby waive this requirement I am the(check one)❑owner ❑owner's agent
Owner/Agent
Signature Telephone No. PERMIT EEE:$
Date...1 '2d9'::"
Y '2d 9'::�"
No ............................
NORTIi7
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
41
10 o
ssACMusf
This certifies that
......................'°.._....c....
..................................................................
t. ..................................................
has permission to perform
wiring in the building of ........ . ....................
at......... . .............. .North Andover,Mass.
Fee.ar.......... Lic NoA.5.,./2,1
' � w
771e Commonwealth of Massachusetts ern..o.e Cody
• , r.r.lt s.. r�
Deportmerlf of Public Safcfy
ecr.pwcr a fee o.ecbel
DOARD OF FIRE PREVENTION REGULATIONS S27 C 200 3/90Piz;
1t,a.e tit.a)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORI<
AN w"It w Le pet6rretd In eccerd.nce rUb.the I•laesschetetts Elictr{cat Cedt. S27 Ct•IR 12:00
92(MUSE YRI1Ff Ili UM OR TYPE AIS. Z1iF01I1ILT1011) • Date. �' �` '
City or Town of _ Dd UEIe To the Inspector of Wirest
St undersivwd applies for a permit to perform the elect9 drical work described below.
laotion (Street L lkwber) d� '�"� Ce T
Oamer or Tenant 4Fy1 N v 6 114-1v
Owaser's Address . S41YE
Is Ithis permit in conj Ion with a building pernit: Yes 1:1 Ito ❑ (Check Appropriate Box)
hrr•ose oflBuiidIng ES/�Fil/ Utility Authorization 110.
Existing Service Amps / Volts Overhead ❑ Undsrd❑ Its. of heters__
Itetr Service Amps /; Volts Overhead ❑ Undgrd❑ Ito. of Heters
T—ber of Feeders and A-opacity
location and Hature of rroposeEilectrical Work G'//4U� sCFT
Tv- of Lighting Outlets Ito. of hot Tubs No, of Iransformers TotKVAl
Above In-
To_ of Lighting Fixtures Swimming rool grnd. grnd, ❑ Generators KVA
Ito. of mer
To- of Receptacle Outlets Ito. of Oil Burners. BatteryEUnitsncy Lighting
FQ_ of Switch Outlets No. of Gas Burners FIRE AIAPJIS Ito. of Zones
Ital Ito, of Detection and
Bac. of Ranges No. of `Air Cond. tons Initiating Devices
ticat Total Total
la_ of Disposals 110, of Pumps , ins KW Ito. of Sounding Devices
:s,_+of Dishwashers S ace/Are: lltating KW 110. of Sel Contained
Space/Ares: Detection�Sounding Devices
ia_ o[ Dr ers Heating Devices rw Local❑ IlunicipaI ❑Other
_s 7 g Connection
Ft3-hof Water heaters KW No, of No. of Low Voltage s
Signs Ballasts Wiring
We. Hydro Itassage Tubs No. of Ilotors Total It?
e .
6431ER: .
rMSURMICE COVERAGEt rursuant to the requirements of Massachusetts General LaJs
I have a currentL1 111: Insurance ropey including Completed Operations Coverage or s aubstant{aI
e�ulvalent. YES( [ I have submitted valid proof of :ane to this office. YES ir 110 (_] IF
11ou have checked YES, please indicate the type of coverage by checking the appropriate box. ?
r
USURAIICE �DotrD ❑ OMER❑ (rlease Specify)
xr ret on UateT
Estimated Value of
Electrical Work S b /
i rk to Start O �l �p Inspection Date Requestedt Rough Flnai
rued :Wader the penalties of/1-et J_Ty �--
ElM KAIM LTC. }i0.
Y ictnsee�l�( ��'1/r�• nZ L��/Sn tic LTC,/ - /},, est LIC. IIO. trL—
�+ddrets A ��iJ'SAlt. Tel. Ito.
Zj —T—Alt. Tei. Ito. 16 RK -
OWHER•S IHSURAIICE WAIVER: ..i am ovare- that tits Licensee does not have the insurance coverage or its stn
st+ntlai equivalent as required by iiassnchusetts General Iivs, an�cliat my afgnature on this permit
srplleation v:Ives this requirement. Owner- Agent (Please check one) _
t
Telephone No. rERIIIT FEE S ��
Signatvte at Wner or gent • .r
< r `�'�