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Home My WebLink AboutMiscellaneous - 49 RICHARDSON AVENUE 4/30/2018 r 49 RICHAR SON 00.0 f 2101031 \ i I / Date...�. .. �. .............. OF NOR7/y,h TOWN OF NORTH ANDOVER 9 PERMIT FOR WIRING - �'$ACHU5E Thiscertifies that ................... ......................... ............................................................ has permission to perform .............. " 4.�b x4 L .... : ....................................................... . . ....... wirin in the building of.......L C-�F`j" ........................................................................................... at ............1..... !..�.:. 1(.�...cS.CS. ..... Q-..................North Andover,Mass. CO Fee t')�D.. ............Lic.No?r1� .................................................................................... ELECTRICAL INSPECTOR Check# � �� PI-2 ff Commonwealth of Massachusetts icial Use P y �.�� D 0 Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEQ,527 CMR 12.00 (PLEASE PRINT WINK OR TYPEALL INFORMATION) Date:_ City or Town of. NORTH ANDOVER To the Inspector f Wires: By this application the undersigned gives notice of his orPr intention to perform the electrical work described below. Location(Street&Number) g �;C/rya C,oA1 Al Owner or Tenant Telephone No. 97R-68?-&W,,6_ Owner's Address R p• Is this permit in conjunction with a building permit? Yes 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: TranSusp.(Paddle)Fans s Total Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Arnd bove❑ In- ElBatter 0.0 Uergency Lighting 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 g Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained p Totals: Detection/Alerting Devices No,of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection No.of Dryers Heating Appliances KW Security oto 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 No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of lectr'cal Work: 000•QQ (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVE GE: 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 pains and penaltie ofper�ury,that the tnf rntation on this application is true and complete. FIRM NAME: . ^/ , I A,/ i LIC.NO.:�ZQ(pL 11 Licensee: 63 6,.jA/ LL)O i, Signature LIC.NO.: (If applicable,enter "exam t"in the license nzun er line.) Bus.Tel.No.: I Address: -� ,� , r tai ,lei/ D/ Alt.Tel.No.: *Per M.G.L c. ,s.57-61,security work,equires ID4artnknt 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: $ 9 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 EN Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP CTION: Pass IN I.X Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSP TION: Pass 0 Failed Re-Inspection Required($.)❑ f Inspectors Comments: r Inspectors Signature: eYZZA, Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts _ Department of IndfustrialAccidents M •.�- :~- 1 Congress Street,Suite 100 _ Boston,MA.02114 ZOX 7 www.mass.gov/dia °�M sys yVor;kerg,Compensation Insurancd Affidavit:Builders/Contxactors/Electricians/P um ers. TO BE FILED'WITH THE PERMITTING AUTHORITY. Please Print Le 'bl AU'•licant Information Name(Business/Organization/Individual): Address: City/State/Zip: r ' Phone#: n Are you an employer?Check the appropriate box: Type of project(irequired); em to ees full and/or part-time).* 7. ❑NeW'donstractlon l.❑I am a employer with P y 2.0 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.F1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole 12 Pliunbing repairs or additions proprietors with no employees. 5.Fj I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13•,0 Rb6f repairs These sub-contractors have employees and have workers'comp.insurance.t 14.0 Other 6.Q We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and We have no empl I des.[No workers'comp.insurance required.] *Any applicant that checks box#1_must also fill out the section below showing their workers'compensation policy information. fi Homeowners who submit•this alFdavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this tiox 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. X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name- Expiration Date:. Policy#or Self-ins.Lic.#: City/State/Zip- Job Site Address: policy number and expiration date . Attach a copy of the workers' compensation policy declaration page(showing the p shable by a Pirie up to$1,500.00 Failure to secure coverage as required under MGL c.152,§25A is a criminal violation puni 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.A copy of this statement may be forwarded to the Office of Xnvestigations of the DIA.for insurance coverage verification. do hereby eerti u der tliepains and penalties ofperjury that the information provided above is true and correct. 1' - ^ Date: Si ature: Phone# / ✓ ��7 "�� Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• �II r 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'defuied 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 6f 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." MG « L 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 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 permitilicense 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 stamp ed 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. Anew 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 www.mass.gov/dia N/F MATTHEW RAE 90.00' ..� ., S24014'10"E -- LOT 28 -:4Exs ORY AREA=5,567 S.F. � CGARAGE=0.1278 AC. 31.88'00 � N Z9 �rW 4.70 32.43' 0 ;"z I ExiTING 4.40' 32,78' : � 2 STORY 0 11.91' W.F.D. " PROPOSED t 0) ADDITION -P 38.19' /v q v�M rn od So DH FND 90.29N19°38'13"W IP FND RICHARDSON AVENUE (PUBLIC-40' WIDE) LEGEND ED SB DH STONE BOUND DRILL HOLE 0 IP IRON PIPE 0 IR IRON ROD W.F.D. WOOD FRAME DWELLING w.F. WOOD FRAME FND FOUND BIT. CONC. BITUMINOUS CONCRETE N/F NOW OR FORMERLY U) 0 NOTES PLAN OF LAND 1. SEE TOWN OF NORTH ANDOVER ASSESSORS IN MAP #31 LOT #20 AND DEED BOOK #2214 NORTH ANDOVER, MASSACHUSETTS o PAGE #116 E.N.D.R.D. FOR SITE. DRAWN FOR a 2. ZONING DISTRICT IS RESIDENCE 4 (R4). LEO LAFOND AND CATHY LAFOND 49 RICHARDSON AVENUE r- NORTH ANDOVER, MASSACHUSETTS 01845 0 111 n SCALE: 1"=20' DATE: OCTOBER 5, 2015 U u') 0 10 20 40 80 00 (l iI 't 1 11MERRIMACK ENGINEERING SERVICES 66 PARK STREET ANDD VER, MASSACHUSETTS 01810 10/5/1 PHONY (978) 475-3555 FAX (978) 475-1448 STEPHEN E. S I L.S. DATE EMAIL.• MERRENG®AOL.COM Cunningham Lindsey U.S.,Inc. P.O.Box 703689 unnin ham Dallas,TX 75370-3689 Lindsey Telephone(888)738-8714 Facsimile(214)488-6766 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS Ch. 139, Sec 3B Building Commissioner or Inspector of Buildings NORTH ANDOVER TOWN HALL 120 Main Street North Andover, MA 01845 Claim Number: A033573601 Policy Number: 63309400003 Company Name: ARBELLA INSURANCE GROUP Date of Loss: 04/06/2015 Insured: LEO LAFOND Property Location: 49 RICHARDSON AVE, NORTH ANDOVER, MA 01845 Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Cunningham Lindsey Catastrophe Department cicat@cl-na.com 800-867-3885