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Home My WebLink AboutMiscellaneous - 47 WILLOW RIDGE ROAD 4/30/2018N O E5 o M om 0 Date.Z� ... // ..- ....-) ...; ............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING 4-1-1 This certifies that ......... ............ has permission to perform ............................................................................... wiring in the building of ......... ................ r .................................................... at ... ...... ....... North Andover, Mass. Fee ... :3 ............ ......... Lic. --a ........ c PI;cm Check # 85[4 a N Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy 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 Electrical Code (MEC) 527 1 MR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: 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) Zl' 9 1-/12-60 L,/ 4-1066 /Z02Q 6' Owner or Tenant 61166 4 � Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No Telephone No. ( 12 _ -71U (Check Purpose of Building Appropriate Box) /jam j��LT/r Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters New Service Amps / Volts Overhead ❑ rd Und g ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:-yl�� /--7 /' following table may be waived by the Tnc�o�m rnd• KW P No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans Transformers KVA No. of Luminaire Outlets No. of Hot Tubs No. of Luminaires Swimming Pool Above ❑ In FIRE ALARMS No. of zone d. - -- No. of Receptacle Outlets �No. of Oil Burners No. of Alerting Devices No. of Switches No. of Gas Burners No. of Ranges No. of Air Cond. Total Local ❑ Municipal ❑Other No. of Waste Disposers Tons Heat Pump Number. Tons Security Systems:* Totals: No. of Devices or Equivalent No. of Dishwashers Space/Area Heating KW ' No. of Dryers Heating Appliances No. of Devices or E uivalent No. of Water KW Heaters No. of No. of Si s Ballasts No. Hydromassage Bathtubs No. of Motors Total H OTHER: following table may be waived by the Tnc�o�m rnd• KW P No. of Total Transformers KVA Generators KVA o. o mergency ig g BatteryUnits FIRE ALARMS No. of zone No. of Detection and InitiatingDevices No. of Alerting Devices IZW No. of Self -Contained Detection/Aiertin Devices Local ❑ Municipal ❑Other Connection Security Systems:* No. of Devices or Equivalent Data Wiring: No. of Devices or E uivalent Telecommunications Wiring: No. of Devices or E uivalent Attach additional detail 'desire d, or as required by the Inspector of Wires. Estimated Value of Electrical Work:&E0-- (When required by municipal policy.) Work to Start: /Z �i��s� 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.%/t, f� �n� CHECK ONE: INSURANCE ff BOND ❑ OTHER ❑ (Specify:) G /? P C . q0J 2 j-7 '7f2 � � I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: G�Z� LZ�z G LIC. NO.: /�3 %3A Licensee: j 4'�Z j G�i5V Signatur of PP gip-, LIC. NO.: a licable, enter "exempt " in the license number line.) d Address: S''- �7—,4AV �/� �� 9111 -1A sV�� 2n 7 `27 Bus. Tel. No.: l;/ 7-9/-�s355' *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. L cl. 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 Signature Telephone No. PERMIT FEE: $ r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 NEashington Street Boston, MA 02111 t ' www.mass.gov/dia . Workers' Compensation Imurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leo-ibly Name (Business/Organization/individual); Address: j G i� \/P M/ �14 G� 7o � `Z7 City/State/Zip:MU2Vi 0212 1 Phone #:_. Are%oou an employer? Check a appropriate box: 1 • I �I 1 am a employer � ❑ with 4. I am a general contractor an g dI em employees (full and/or part-time).* 2. ❑ I am a sole proprietor or have hired the sub -contractors listed t partner- ship and have no employees on the attached sheet These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its regmred.] 3. ❑ I am a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No -workers' comp. c. 1.52, § 1(4), and we have no insurance required.) t employees. [No workers' comp. insurance required_] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition q•Elilding addition 10. Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other t h - – —, ` ""Our our me section below showing their workers' compensation policy information. omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. iContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' con p. Y l:c; is 7,a«on. I am an employer that is providing workers' compensation insurance for my employees: Below is the policy and job site information. ' M Insurance Company Name: Policy # or Self -ins. Lic. #: -,/—a1%7 _ Expiration Date: / Job Site Address: t % 4�j�f�(i✓l ��-t� City/State/Zip: lVz �%✓�� /�%� C�l� Z%� 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 5250.00 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 der the ins end penalties of perjury that the information provided above and correct Si lure: Date: Ofrxial 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 #: ti Information and Instructions C 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 -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 city or town that the .application for the permit or license is being requested, notthe 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 numberlisted 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 policyinformation (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 bum 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 1-8.77-MASSAFE Fax # 617-727-7749 Revised 5-26-05 W vxv-mass.bov/dia TOWN OF NORTH ANDOVER Building Department 1600 Osgood Street Building 2- Suite 2-36 Building Dept North Andover MA 01845 Tel: (978) 688-9545 Fax (978) 688-9542 COMPLAINT FOR INVESTIGATION DATE: TEL #: q 7 i -6t b3 j b NAME OF COMPLAINTANT: J-) /'.,A 4rNe(tel < < I A ►�a �� !v /V ADDRESS: COMPLAINT TYPE: Electrical: Plumbing: Gas: Building:il� Property Owner: -t- hvz 941c�� Address: 5� �� ✓� rJ�, Signed: Complaint Form - Revised 6.2007 K TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that has permission to perform .' !� ' : !� .. z........... . plumbing in the buildings of�.-?':: . ..................... at ...y . G`' c-¢�,. ��-,�! . , .. , North Andover, Mass. Fee ..... Lie. No a°�!Ss"L -.:..�PG NSPECTOR Check # 7 9 -4- 5 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location U ,l O Owners Name c l 1 PeAj Date Permit # 7sS Type of Occupancv Amount s a New El Renovation Replacement Plans Submitted Yes ❑❑ No Ti YV rMTr*b r,r. 11 L111L U1 Lype) Ir'stalling Company Name V Check one: Corp. Certificate // LL ❑ Address Ct? �c a T rN Partner. usmess Telephone � Fi � rm/Co. Name of Licensed Plumber. v Insurance Coveraze• Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity F1 Bond ❑ Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ F1Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massach;'�Cr is tate lu - and Ch ter 142 of the General Laws. By: ignaturMcens um Da Title Type of Plumbing License City/Town :J�Q 4L cense umoer Master ❑ Journeyman jay APPROVED (OFFICE USE ONLY!�:! 97 L 5 Date ...... / 0..,. a 7,10 ......................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ............................. ... . A..Q.........7 ................................................ 6 /) _See- I has permission to perform .................................................. -5 ................ wiring in the building of ............... ........ ..v ...................................... ............. 7-,O ... at .... L-.C'L.'.Af.9.q ........... .1 ..... 7 North Andover, Mass. Fee ... Lic. No. ...... Z2�4 Check # 741 i animorurr 0��/77/I� O::7- APPLICATION eLlePartrnercto��ire�ervires Permit No.BOARD OF FIRE PREVENTION REGU9LATIONS Oc�an`yandev.11 e FOR PERMIT TO PERFORM ELECTRICAL WORK All woiic to be performed in accordance with the Nfacc� Electrical Code (MECO, 527 CMR 120o PPLEaS'EPRINTININK OR TYPEALL INFORI M YOA9 Date: 1 Udl,-L-4 1d City or Town of. ky44( &JGvj-r To the Inspector Of Wires: By this application the undersigned gives notice of his or her intention toerform the electrical, work described below. Location (Street & Number) Owner or Tenant S`f~Q v.Q �• ,l s 1 Ccsy Telephone No. —9)j, GSA �? U �3 Owner's Address <I4 {✓ Is this permit in cont uncfion with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorizafion No. ExistingService Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps - / Volts Overhead ❑ Undgrd ❑ No. of Meters N b um er of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Com letion of the ollowin table be waived by the Impectar of Wjres 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 ergency rg tm9 Lrrnd. d. Butte 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. TOS No. of Alerting rting Devices No. of Waste Disposers HeatrPnmP Number I Tons I KW No. of Self -Contained No. of Dishwashers Space/Area Heating KWLocal ❑ E—n 5pal ❑ me, Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or E uivalent No. of Water KW No. of BNo.al of Data Wiring: S Ballasts No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: Attach additional detail if desireg or as required by the Inspector of W2 -,es. Estimated Value of Electrical Wo0c3municipalcy ) s' (When required by po • h Work to Start.1g, S',,q, r Inspections to be requested in accordance with EC Rule 10, and upon completion_ INSURANCE COVERAGE: UM nless 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 equival&nt The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CRECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) Self Insured I certify, under thepahn andpenables ofPe7Wl', that the information on this apppicadon is true and complete FIRMNAME: ADT Security Services Inc. LIC -NO.: C-45 Licensee: Mark A. Brophy Signature LIC. NO.: C-45 afaPPlk� "exempt " in the license resmcber line) Bus. Tel. No.- 81- 5 - 5 619 3 5 Address: 410 University Avenue Westwood MA- 02090 Alt TeLNo.•741-355-5500 *Per MG -L a 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. 0 .0953 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 en Owner/Agent Signature Telephone No. PER1Y UFEE: S Lis t.