HomeMy WebLinkAboutMiscellaneous - 5 Village Green 5 VILLAGE GREEN
210/046.0-0096-0020.0
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NORT1� �
3?p�tr�`D�+°'eMOpt TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
ass^CHus�
This certifies that .c�U.U-/C--
..... . .......
has permission to perform .......
wiring in the building of....
at..... bjQ.................. .North Andover,Mass.
Fee.:. X..-�"' Lic.No. 7./
..... . ........ .
p� ELECTRICAL INSPE
Check # CJ�7
8965
' / //i/ ficial Use Only
orr�manu✓eah�fof a5yachrsbe�� Of
t� l c� Permit No.
2apartment ol5ire Serviceb
Occupancy and Fee Checked j
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORIN ELECTRICAL WORK
All work to be performed in accordance with the A4assachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: August 24 , 2009
City or Town of: N. 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) 5 Village Green Drive
Owner or Tenant Village Green Condos Telephone No.
Owner's Address PMA/ (9 7 8) 683-.4101
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building Commercial Utility Authorization No.
..,,. i-g-5crvice Ai:]pS Volts fir... Cw-.'.� U UrtitStd u iv U. iit ivieiers
New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical M'Qrk: Replace main breaker _
Completion of the folloia'ino table may be waived by the Ins ector of YPires.
No.of Recessed Luminaires No.of Paddle Ceil.-Sus . No.of Total
P (Paddle)Fans Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators R`'A
Above In- 'o.o mergency ightmg
No.of Luminaires Swimming Pool grnd. ❑ arnd. ❑ Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No of Detection and
No.of Switches No.of Gas Burners �y v Initiating Devices
Total II �, !I
No.of Ranges No.of Air Cond. Tons iT o.of Alerting,Devices
No.of Waste Disposers Meat Pump Number Tons KW No.of Self-Contained
p Totals: I I I ................. Detection/Alerting Devices
No.of Dishwashers Space/Area heating KN81 (Local❑ Municipal ❑ Other
Connection
No.of Dryers Hearin-Appliances Kms' Security Systems:
J No.of Devices or Equivalent
No.of Water No. of No.of Data Firing:
(Heaters RW Signs Ballasts No.of Devices or Equivalent
I No.hydromassage Bathtubs No. of Motors Total IIP Telecorr:munieations Wiring: �
t
Nc tri ccs— i.>alc:t
OTHER:
Attach additional detail if desired, or as required by the Inspector of 111h-es.
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 KI BOND ❑ OTHER ❑ (Specify:)
I certify,under thepains andpenaltiesofperjury,that the information an this application is true and complete.
FIRMNAME: Crowe & Sons Electrical Co p . LIC. NO. 17i68A
Licensee: James B. Crowe Signature LIC.NO.: 171A
(If applicable,enter "exempt"in the license number line.) Bus.Tel.No.: 453-6-096
Address: 576 Middlesex Street , LowelY7 Ma 01852 Alt.Tel.No.: -6696
*Per M.G.L. c. 147,s.57-61,security work requires DepartmeV of Public Safety"S"License: Lic.No. �S CQ 001051
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 PERMIrT FEE: S 55 .00 -
Signature Telephone No.
t�
Date.... .. ..�.7.."
e HOR7p,
• " '••."° TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
,SsACMUSE�
This certifies that ............................................/.�� .................................
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has permission to perform /.. .:~.-.:t. Z -Y G°
wiring in the building of.....� .....v��
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at................
........................................../................,North Andover,Mass.
Fee..... ..'. .:z..... Lic.No. .......... ......... .s?.. ............. ....l.l.............
ELECTRICAL INSPECTOR
Check #12 2 t
8184
Date........�.. '......Y....
NORTPI
°t,"`° TOWN OF NORTH ANDOVER
ri
PERMIT FOR WIRING
... ;,SSACMUSE�
This certifies that ......................
has permission to perform ................ ................................
wiringin the building of...................................................................................
at.........S G4, 1, ../V,-4 .......................... .. orth Andover,Mass.
do
Feed........... Lic.No.............. ..................... ..t.........
EL CTRICAL INSPECTOR
Check #
8327
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Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
Occupancy and Fee Checked "_
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank
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: b -- 12- p S:�
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) 1-4 y 1 t~ G e -AJ Cl `f
Owner or Tenant f)Q u t 9- Dot n t c-l l e Q a 11(i VC) Telephone No.
Owner's Address S V t t tp- p (,_to ,,
Is this permit in conjunction with a building
++permit? Yes � No ❑ (Check Appropriate Box
Purpose of Building S t V-. h Ie 1Nt.t I Utility Authorization No. 7
Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
i
Location and Nature of Proposed Electrical Work: t,(/_ r,K� fa kLe w l-1 C G 1^ a a r C.
,cp
Completion o the ollowin table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)FansNo.of Total
.- Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators K-VA
No.of Luminaires Swimming Pool Above ❑ In- ❑ o.of Emergency Lighting
rnd. grnd. Battery Units
No.of Receptacle Outlets 3 Q No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
InitiatingDevices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons g
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
a --� Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water No.of No.of
Heaters KW. Data Wiring:
-
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: (,�l 2 Q 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 pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: c/ T K LIC.NO.:--Iq Z 9
Licensee: J o-&en h fr �Q vi S Signature LIC.NO.:
(If applicable, enter"-exempt"in the license number line.) Bus.Tel.No. Q Z�lfd� 2�3
Address: ,(oo p2 a S a n /-� 1- (�- 'Yt p( U (�Q > h Alt.Tel.No.: 1P'kZS L;1(3r'
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 �v
Signature Telephone No. PERMIT FEE: $ f S -
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
"�•' ° 600 Washington Street
rtEi t i �
i Boston, MA 02111
t�= www.nxass.gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/individual):_ (r L t60 tE c r
Address: l(so Plea a 1,1- SL►
City/State/Zip: 1Uo r¢:h 4-n a v-P i, Phone #: . q 7d- 6&7 a-?� 3 -
Are you an employer?Check the appropriate box:
Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. 2-<ew 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.x 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8. Q Demolition
working for mein any capacity. workers' comp.insurance. g, ,Building addition
[No workers'comp,insurance 5. [g'fNe are a corporation and its 10 0 Electrical repairs or additions
i
required.] officers have exercised their
{ 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself,[No-workers'comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.]t .employees. [No workers'
comp. insurance required.] 13.❑Other
Any applicant that checks bore#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 their workers'comp.policy information.
I am an employer that is providing workerscompensation insurance for my employees: Below is the policy and job site
information.
Insurance Company Name:
+ Policy#or Self-ins. Lie.#: Expiration Date:
j 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.
I do hereby certify under the pains a penSjtkf of perjury that the information provided above is true and correct
Signature: Date: t 2- Ori
Phone#: q 7 y ? _r) -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):
j 1. Board of Health 2. Building Department 3.City/TownClerk 4. Electrical Inspector 5.Plumbing Inspector
6.other
Contact Person: Phone#:
G,
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 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,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 tine.
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 permittlicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Jab 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 lndustriai Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-8.77-MASSAFE
Fax#617-727-7744
Revised 5-26-OS www.mass.gov/dia