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HomeMy WebLinkAboutMiscellaneous - 50 HIGH STREET 4/30/2018 �� ��GN ��� �t � �� i k i i �` RECEIVED PAYMENT Vy Date...... , IAN 2 6 2016 NORTHANDOIOWN OF NORTH ANDOVER o n SURER-COLLECTW PERMIT FOR WIRING CHO This certifies that ��/ ✓ ... llckl—o .. ........................................................................ has permission to perform ....... . 1, tf "/Qo .............................................. ...................................... wiring in the building of.......,. �,C9– . ....... .............................................................................. at ........ `v } .�.. ............!... .....A over,Mass. Fee.�-*..........Lic.No. ................1V17 ....... ........ ...........................///........ /y sy/ ELECTRI INSPECTOR /� �d � sty Vol it i �Ij _T 43c�cG � y � � i E 9 j 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(Iv1E ),527 12.00 (PLEASE PRINT 1N NK OR TYPE ALL INFORMATION) Date: I la6 City or Town oh NORTH ANDOVER To the Inspect r of ices: By this application the undersigned gives notic ,orf his or her intention to perform the electrical work described below. Location(Street&Number) �4 p S Owner or Tenant 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 / 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: �ti c "--/Z _. Lf Completion of thefollowing 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- ❑ No.of Emergency Lighting rnd. grnd. Battery Units i+t - 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 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 IIP Telecommunications Wiring: No.of Devices or E uivalent [OTHER, Attach additional detail if desired,or as required by the Inspector of LVtres. Estimated Value of El e tric 1 Work: (When required by municipal policy.) Work to Start: 9' Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO 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 pain nd penalties of perjury,that the information on this application is true and complete. FIRM NAME: . c�►.I Z �� LIC.NO.: G 3/7_Tj Licensee: - n v—Yea Y-- Signature LTC.NO.: (Ifapplic'able,enter "exempt"in the license number#qe.) Bus.Tel.No.- fP0—Y50'�J•y� Address: 3� �"4 �v+ti s�i✓ aiv dn Alt.Tel.No.: *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. I U ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule S: 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 t 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 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: s+ Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: �— i,1 t s �� t Inspectors Signature: Date: —/6 ROUGH INSPECTION: Pass 0 Failed IN Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com i t The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street,Suite 100 1,15 ' d021Y4 2017 - Soston,MA. �r www rnass.go v/dia e Affidavit:Builders/Contractors/Electricians/Plumbers. VPorkere Compensation Insuranc TO BE FILED WITH THE PERMMTTING A,UTHOR"y- Please Print Le 'bl A ''licant Infoxnuation ' Name(Business/Oigabization/lndividual): �K , l L a✓( Address: ` ' O'`J Phone#Z0,4150 City/State/Zip: Check Elie appropriate box: Type of project(required): Are you'an employer? 1'0 I am a crop loyer with ( em to ees full and/or part-time).' 7. [1Nevv'donstructlon � • P y 2.❑I am a sole proprietor or partnership and have no employees VVorking for me in 8. []Remo deliiig any capacity.[No workers'comp.insurance required] 9. ❑Demolition 3.Q 1 am a homeowner doing all work myself[No workers'comp.insurance required]t 10 Q Building addition 4•❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will l l[]Electrical repays or additiogs ensure that all contractors either have workers'compensation insurance or are sole ' Pl- bing repairs ox additions proprietors with no:eniployees. 5.❑1 am a general contra cfor and I have hired the sub-contractors listed on the attached sheet. 11 Q Roof repairs These sub-contractors hav6 employees and have workers'comp.insurance t 14.Q Other 6.[]We are a corporation and tis,officers have exercised their right of exemption per MGL c. 152,§1(4),and'we have"employees:[No workers'comp.insurance required.] Any applicant that cheoks bbx#i must also fill out the section below showing their workers'compensation policy information: At Homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such zi�: •. #Contractors that check this box must attachedan additional sheet showing the name of the sub-contractors and state whether or not(hose entities,have employees.'If the sub-contractors have employees,they must provide their workers'comp.policy number. X am an employer that is providingworkers'compensation insurance for my employees. Below is the policy and job site information. I Insurance Company Name: I Expiration Date: Policy#or Self-ins.Lie.#: City/State/Zip--b o Job Site Address: / L Attach a'copy of the workers' compensation policy declaration page(showing the policy number and expiration date). e by a fift up to 0.00 Failure to secure coverage as required undeviMenalties?inthe farm of criminal25A is a T PrWORK ORDER olation Iand a fine f up to $250.00 a and/or one-year imprisonment,as well as z p day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage'verification f do hereby certi u or the pain and penalties of perjury that the information provided above is�G e and correct Date• Si ature: Phone#: ot write in this area,to be completed by city or town official. Official use only. DOB l. Permit/License City or Town: # Issuing Authority(circle one): 2.Building Department 3.City/Town 1.,Board of Health. Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person- 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 ente rise and including e ,l rP g th legal representatives of a deceased employer,ox 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 ofthe 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 requi"red" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for theperformance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Pleasb 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 regwired 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 permittlicense 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(ifnecessary)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 www.mass.gov/dia • P. 1 Communication Result Report ( May, 5, 2016 9: 10AM ) 1) Town of North Andover 2) Community Development Date/Time : May, 5. 2016 8:46AM File Page No, Mode Destination Pg (s) Result Not Sent ---------------------------------------------------------------------------------------------------- 7401 Memory TX 812077671315 P. 1 E-2) 2) 2) 3) 3) P. 1 ----------------------------------------—---------------------------------------------------------- Reasonfor error E. 1) Hang u or line fail E. 2) Busy E. 3) No answer E. 4) No facsimile connection E. 5) Exceeded max. 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PaAt�J 2 /� Inspeclo.comments: 1 ChedsP 23 s [ �2dJ 61% Inspectors Signature; 'Date: 1� OUGH]NSPECTION. ` P—M Failed© Ee-1n ecn------coil$,)- W.Q..C-,—�e: Date• : Farw fL-In ----- fns ettors Signature• Date: nEB 1NE1tdHmD...TWJN eFWFTxRIGMr:eeA ,w..aa„rnrar.,..„.,r,.,�__.,,.„ P. 1 ° Communication Result Report ( May, 5. 2016 8: 25AM ) 1) Town of North Andover 2) Community Development Date/Time : May, 5. 2016 8: 18AM File IPage No, Mode Destination Pg (S) Result Not Sent ---------------------------------------------------------------------------------------------------- 7400 Memory TX 812077671315 Pr 1 E-3) 3) P. 1 ---------------------------------------------------------------------------------------------------- Reason for error E. 1) Hangup or 1 i n e fail E. 2) Busy E. 3) No answer E. 4) No facsimile connection E. 5) Exceeded max. 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'W PNaP aa!lamAbo m vup•wu,A Ap aP pmm as!!rys laund I•rW,h PNr?a 511N'4">d,ap oe6q y,pd»»oa,a rep wg,>!IddeTmaaaiayp JP>@nnrd aq�ao ' DrPl appayre'mP>9riauPw'pUa++mp!wm'Jxpm�muP,ugrana9l[e�7Nr61sW>roPeflaunujaaimoYpenWolu�uo!!sq!dd.P!mra *,x I'm e'mVp'-Xw--d�e!gm w..Df BfiRI§OPL[ffi©LLSquaaPaamtl>eaJ Falar.lAaDz^rTPnel4idLC P, 1 Communication Result Report ( May, 17. 2016 12: 21PM ) r 1) Town of North Andover 2) Community Development Date/Time : May, 17. 2016 12:09PM File Page No. Mode Destination Pg (s) Result Not Sent ---------------------------------------------------------------------------------------------------- 7491 Memory TX 812077671315 P. 1 E-3) 2) 3) P. 1 ---------------------------------------------------------------------------------------------------- Reasonfor error E. 1) Ha ng, up or line fail E. 2) Busy E. 3) Noanswer E. 4) No facsimile connection E. 5) Exceeded max. E—mail size E. 6) Destination does not support IP—Fax Commonwealth of Massachusetts O&deluseonW Department of Fire Services Ptam rxa. fI S1� BOARDOFFIREPREVENTIONREGULATIONS APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All wed:to hrpgfwmeai¢—.,&—A& (k St7 12.00 (PLIUSYnAT AWOBTr.PSAUBffom anm Date: t 6 IG GlyorTownof:NORTHANDOVER To&bupe rof)rrw By Us eppliftkan the nedmaigaed givrsnot'i'n))of1�or her itdnulioo toP.,knn ft obckicalvnk d=Uodbslow Loralion(3trat�Numhsr) .�� f�1J� S'-/� Orvnet erTeaeal TelVI—Na Osmersr Addree Is Bsis permit is cos�unegau nitliabuUdi�permit? Ya❑ No❑ (ChokApprop0m.18oz) FurpoaeofBuUalvg UtilityAuUwr&WonNw Bria4ngSsrviw^Amps / Vohs Overhead❑ Vadgrd❑ No.of Meters New6ervlce Amps f -W% Ovrrhmd❑ Uadgrd❑ No.ofMetem NWoberofFerdua and Au,acity IAeauoo9ndN0.ture at]'ropos¢d Electrical Work: C kfimio eye (nui rabk 6a uwn+.Ab Ma vnror 1� Na.afdtettaged Lusuioairet o.offk2k,Suap.(Paddle)pam o.ofofa .......--:....:.'�-,.,...:._.:.,..•—._-._,. -,—.,_______ Transfesmsaa KVA ....:...:......_,..:-:..r.-...- asim RVA RECENED PAYMENT mergen¢f ng �r ')VN 2 610 16'' / ALAA0f3 Mw of Zunn _ N-MANODMWN OF NORTH ANDOVER IaUistln Deri�s • URER-0OLIECI •o.ofAlutingDevires o.ofst-Goa ed •a'D'?+'": tectivNA�enrfi�nDaDevices .::od(]Connedlsa �OIMr —` '� / No.�of •:e y or E ufvalrnt ' This corti5es �_._.._ has pernsissionmpeif'otm_ //�n?-d...... 1-�� -1po/>..ss a ymmD I tioseB uu� t wrong in the lmildiug of_.._1&'rb--'�'�� tt._ iu ovetB—� Q Jrry¢wdtyrhrr mem y13.s L' _.___ Fee Nr..�-_.._....Ui N.�/?/7 Policy CCC3J(.. - - -- In ei..noh �+ Rib10,aodupoaeomp1.Uon. .. ,` yr ofrtahiwd wox4:nsay tseua uniosr � R - .. �orib sobstanlial equivalent.7lta . ..r�M1'`!:�.''=��:'.; .• 'nirriueondcotnpYd¢. .,.'MRMNA7rlE•_ 1C {-� •C, I.Ic.N6_ {Q 3/7.3 IRc®uoe: n lf.. Slgaamre LIC.NO.: -----lAnbfs,nee." "MMrltc ca aconerr' ) But.Tel.No.•F�--4a�'vs•Y), Adaets: 3Y1 f lkrncAf. , .� 177 Alt 7eL No.: 'FaMG.La 147,s.57-62,xe 'requiresDepm�tu mtofya11ic3afety"S"Lie®sa: ISe.No. OWNER'S IMURANCR WAIL'RR:I atn awatetbat1keLicaasae dwx Wert hwa tlu:Ymbilityinsutauw oovo7agelmrmally regnuedbylaw.Bytt�slguaturekelarv,Ihemby wasYatlsia raquizcment.Iamlhe(cheekon)[owner ❑oumur's unt. atur�e� Tel PEBAIITFBE:5 � i gn ephonetgo. 5/18/2016 Town of North Andover Mail-Re:Message from"CommDev-Ricoh" NURT '4'U.V i R Massachus�s Maura Deems <mdeem s@northandoverma.gov> Re: Message from "CommDev-Ricoh" Rick Casey <rcasey@emcinc-online.com> Wed, May 18, 2016 at 7:10 AM To: Maura Deems.<mdeems@norfhdndoverma.gov> Cc: Kayla Kunath <kdhanson@emcinc-online.com>, Seth Zeren <szeren@rcg-Ilc.com>, David Steinbergh <dsteinbergh@rcg-llc.com> Good morning Maura. For some reason I cannot re-open the file you sent me. Would you please re-send it to all copied on this email. Th k you. Richard A Casey Sr. Project Manager Energy Management Consultants, 55 Industrial Way / Portland, ME 04103 Office (207) 767-1313 c� Fax (207) 767-1513 -� Cell (207) 807-3377 Rcasey@emcinc-online.com www.er �nc-online.com q On May 17, 2016, at 12:25 PM, Maura Deems <mdeems@northandoverma.gov> wrote: Please see attached as requested. Thank you, Maura Deems Building Department Assistant Town of North Andover ------ Forwarded message --------- From: <spiceworks@northandoverma.gov> Date: Tue, May 17, 2016 at 12:31 PM Subject: Message from "CommDev-Ricoh" To: "Deems, Maura" <mdeems@northandoverma.gov> This E-mail was sent from "CommDev-Ricoh" (Aficio MP C4502). Scan Date: 05.17.2016 12:31:43 (-0400) Queries to: spiceworks@northandoverma.gov https://m ai I.google.com/m ai I/ca/u/O/?ui=2&i k=aeO2b3b5c4&vi ew=pt&search=i nbox&m sg=154c38fdO329d6dO&si m l=l W38fdO329d6dO 1/2 5/18/2016 Town of North Andover Mail-Re:Message from"CommDev-Ricoh" Maura Deems Building Department Assistant Town of North Andover 1600 Osgood Street Bldg. 20 Suite 2035 North Andover, MA 01845 Phone 978.688.9545 Fax 978.688.9542 Email mdeems@northandoverma.gov Web www.northandoverma.gov e� 'Eat • Please note:As of January 11, 2016, all Town Hall offices, exce t Assessor and Veterans Services, will be temporarily moving to 1600 Osgood Street, Suite 2043. All email messages and attached content sent from and to this email account are public records unless qualified as an exemption under the Massachusetts Public Records Law. Visit us online at www.northandoverma.gov. <201605171231.pdf> https:Hmai l.google.com/mai I/ca/u/0/?ui=2&ik=aeO2b3b5c4&view=pt&search=i nbox&m sg=154c38fdO329d6dO&si m l=154c38fdO329d6dO 212 Date.-3/z-/�/. ...... 1169 �NORTH TOWN OF NORTH ANDOVER ° 9 PERMIT FOR PLUMBING ? �l7 °+,nc'I�S•�9 This certifies that.........v.........`........OJ...........(vl�.................................................................. O YtsL _S,_*/� has permission to perform....................................... plumbing in t�e building of............... ... ......... at........................ ..... .........., North Andover, Mass. Fee 9c� a.."..........Lic. No.2! F 74�r.. ................................................................................. PLUMBING INSPECTOR Check# t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK � CITY -VQ011 12 MA DATE PERMIT# JOBSITE ADDRESS y OWNER'S NAME I R 0a L OWNER ADDRESS VA D� E�"Vl��� TEL FAX P RESIDENTIAL TYPE OR OCCUPANCY TYPE COMMERCIALS] EDUCATIONAL PRINTPLANS SUBMITTED: YES NO© CLEARLY NEW: RENOVATION: REPLACEMENT: Ell FIXTURES I FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 i BATHTUB CROSS CONNECTION DEVICE { DEDICATED SPECIAL WASTE SYSTEM - DEDICATED GAS/OIL/SAND SYSTEM --- — -- DEDICATED GREASE SYSTEM -- I ---- __S - - i -- I -- ! DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM — DISHWASHER { _-_ ___ .�_ _-- 14 j ._.-...J l DRINKING FOUNTAIN I - FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN S _._...! ._._._^i _-.^S _...--.1 ..._—.! -.___�_! ._-_--� .�.....J -_____! ----•-� ...�_.� SHOWER STALL _i .__.—I SERVICEIMOPSINK I __.I _._I ._ { ____I __J TOILETURINAL S _—.- 1 __ _{ _____.{ .__.1 ___..I . __� _____! •I _` , — I ...__._! __. ._._I __..._-_f j __� S _.__1 _--_.J WASHING MACHINE CONNECTION I ) -- WATER HEATER ALL TYPES WATER PIPING OTHER I t I __.__.1 _ i p f S - ( - INSURANCE COVERAGE: 1 have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[ ]I NO _ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER TYPE OF INDEMNITY EI BOND 0 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. CHECK ONE ONLY: OWNER 0 AGENT �0 SIGNATURE OF OWNER OR AGENT and accurate tO ffle 1011 I hereby certify that all of the ddetnstalla d in fo matio I have ander he(permit issued for his application wng this llill be i ation acre trul ance with all Pertinent e rt lien of the —knowledge and that all plumbing work an P Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ f J� I LICENSE# SIGNATURE IMP[ , JP Q CORPORATION #=PARTNERSHIPE3#®LLC�t#Si COMPANY NAME i ADDRESS - CITY �f 1 1 C�+ _.-_I STATE ZIP O U TEL FAX _,_,_ � CELL E � 7 EMAIL 47 ".-_ - _.._._I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECUOD#NOTES Yes No -<c ,�-F L6 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES � I The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information , • Please Print Legibly Name(Business/Organization/Individual): 3&2e5- Ct ff Al f /`�n 74 l�1 Address: ?�/ r) (& .51- City/State/Zip: g rV9 d 307hhone#: Y 7'S �a 7-0 Are you an employer?Check t]ieappropriate box: Type of project(required): 1.❑I am.a.employer with employees(full and/or part-time).* 7. ❑New construction 2. I am a sole proprietor,or partnership and have no employees working for me in g. E 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 I ❑4.E]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12:WPlumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.) 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] ,1 *Any applicant that checks box#1'must also fill out the section below showing their workers'compensation policy information. I Homeowners who submif 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-conixactors have employees,they must provide their workers'comp.policy number. I aril 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.Lie.#: Expiration Date: Job Site Address: !7 / City/State/Zip: IV,, 4,X1D)w-1 4-7A Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration d te). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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 penalties of perjury that the information provided above is true and correct. Signature: 2 Date: Phone#: 97 1 ~ �� 3 - '799 Official use only. Do not write in this area,to be completed by city or town official.. i 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#: 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 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-AIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia r ti COMIV�ONWEQ`LTH OF MAS$ACHUSETTS gpARD Ot F PLUMBERS AND GASFITT.ERS .' ISSUES..THE FOLLOWING LICENSE tw JOURNYMANaPLU BER �Z L i C'E.115ED' AS A.. Ix S J'AME5 P GREENE y, 4 N i 4 BRIG E SALEM 4`�H 030,79 327,E COMMONWEALTH OF MASSWQ ETTS • BOARD U� RFl, T `RS , PLUMB,- :.., ISSb1 S 'THE FOLLOWtNG Lfi ENSE L GENSED'' AS A..MASTER PLyJM6! R. V, JAMES P GREENS i �,'� . 74 BRIDLE ST w SALEM NN` 0.3079-3273 tt2 0101{t� 240 Date.1..f..." OF r►ORTI♦, �.•_' :�•��o� TOWN OF NORTH ANDOVER o 7D PERMIT FOR WIRING cHuss This certifies that 4-:..:........-....................................................................................... has permission to perform '.....,...,., .��...�..�. ?................................................................ ,. wiring in the building of............ �G at ...........T-.0.......!�1..!l�.11....s .� l 77 � ............../.5.. .... ............�North ndover,Mass. Fee.(.2'.".:�........Lic. No. ................. ... ..�... .�'.. ELECTRICAL INSPECTOR Check# Z x ; 00 -1 K jj()k o I w A �. � - 1 C� �M s � 1 fle i2 vin Commonwealth of Massachusetts Official Use Only ' Department of Fire Services Permit No. a Occupancy and Fee Checked CM BOARD OF FIRE PREVENTION REGULATIONS [Rev.i/07] (ieaveblank 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 NK OR TYPE ALL INFORMATION) Date: ���L 3/f 5 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) So /i1 C,k 5'r'GG 1 SU 1-C, ?,It Owner or Tenant 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 / 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:Susp.(Paddle)Fans No.of Total A Transformers KVA No.of Luminaire Outlets No,of Hot Tubs Generators KVA ;1 No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency ig tmg rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No. of Zones No.of S-Ditches No.of Gas Burners No.of Detection and Initiatin Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump I 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 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 Wiring: �k$ No.of Devices or Equivalent f OTHER: ON Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Elec ical Work:�73-W (When required by municipal policy.) Work to Start: I Z3 1 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. CHECK ONE: INSURANCE ElBOND ❑ OTHER ❑ (Specify:) I certify,tinder the Pand penalties ofperjury,tltat the.information on this application is true and complete. FERM NAME: . Witis tii i,i C0-XS 353c— LIC.NO.: Licensee: Signature LIC.NO.: (If applicable,enter "exempt"in the license number line) Bus.Tel.No.• Address: Alt.Tel.No.: 5i,B �.q� 7 7 Ccl� *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 rPEhMIT FEE.$/7-�— 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 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ y Inspectors Comments: r Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP CTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: 42 Inspectors Signature: ,l Date: S FINAL INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: 2-.P-'I.` DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com r The Commonwealth of Massachusetts r Department of industrial Accidents 1 Congress Street,Suite 100 Boston,MA.02114-2017 www.mass.gov/dia ODM 5J� Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNHTTMG AUTHORITY. Please Print Le 'bl A ' licant Infoxmation f LSU(/�l'�.v✓aCet l Lc� rf"�ti Name(Business/Orgabization/lndividual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of o'eet(xeqnired): em o frill and/or part-time).* 7. N6W`constri dlon 1.Q I am a employer with • • P tyees( 2.�am a sole proprietor or partnership and have no employees working forme in 8. RemOdeliiig any capacity.[No workers'comp.insurance required] 9, ❑Demolition 3.E]I am a homeowner doing all workmysel£[No workers'comp.insurance required.]t 10 Q Building addition 4,❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that;O contractors either have workers'compensation insurance or are sole 11.❑Electrical repaixs or additions proprietors With no employees. 12�O.pl,'umbing repairs or additions 5.❑I am a general contra.do and I have hired the sub-contractors listed on the attached sheet. 13% Ro6f repairs These sub-contactors have employees and have workers'comp.insurance. 14 n.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 employees:[No workers'comp.insurance required.] ' .1 it�a.<A I *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who sub 4this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such t6', $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. X am an employer that is Pro vidingworkers'compensation insurance for my employees. Below is the policy and job site information. �(� flu' 1 Insurance Company Nance: ' Expiration Date: Policy#or Self ins.Lic.#: City/State/Zip: Job Site Address: Attach a copy of the�vorkexs'compelisation policy declaration page(showing the policy num bex and expixatxoxt date). on punishable by a into up to$1,500.00 Failure to secure coverage as required under MGL e.152,§25A is a criminal violati and/or one-year'imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to $. an a day against the violator.A copy of this statement may be forwarded to the Office of investigations of the DTA,for insurance coverage verification. X do hereby certify un tlae pains a enalties of peijury that tlae information provided above is true and correct. 4- Date: SiMature: rG6� Phone#: Uva 7-0-87 FF6.Other e only. Do not-write in this area,to be completed by city or town official. or Town: Permit/License# uthority(circle one): f Health'2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Phone4: erson• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their pn ployees. 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 dewed as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enferprise,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 occupaiti 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 b6 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(1)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for theperformance of public work until acceptable evidence of compliance with the insurance requirements ofthis 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 anLLC 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"fob 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 16 Date... ..... ....... .................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHU This certifies that M140 .5kG'i Pj ( aj . ............................................................................. .............. ...............I -� f—�SA � 0 .........F....[ has permission to perform ...................;............. ........... V*).... S� wiring in the build' g of........��.�`:................W..Q............I............t............................... �--+� at .................................... .........................North Andover,Mass. FeCA5. ............L'i;�N o. .................................................................................... ELECTRICAL INSPECTOR Check 4t Commonwealth of Massachusetts Official Use Only 0 el Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [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 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL.INFORMATION) Date: �/41 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perf the electrical work described below. Location(Street&Number) Owner or Tenant Y. 40/0 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Ys No ❑ (Check Appropriate Box) Purpose of Building eV"bit, 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: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. Batter 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 g Tons No.of Waste Dis osers Heat Pump Number Tons I.KW _ No.of Self-Contained p Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Other Connection No.of Dryers Heating Appliances KW SecN to.o Systems:* s or Euivalent 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: li I ti Inspections to be requested in accordance with NEC 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 enallies ofperjurp.that the infornta n this application is true and complete. FIRM NAME: . LIC.NO.: Licensee: Signature LIC.NO.: (If applicab e,enter"exem t" 'n the Z'c a tmb r line. Bus.Tel.No.: Address: Alt.Tel.No.: *Per M.G.L c. 147,s.51'-61,security work requires Department or Pu afety"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 FEIZWT 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 permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed Ir 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 M Failed IN Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ` SERVICE INSPECTION: Pass IN Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 1E Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INS CTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: 4-7 Inspectors Signature: G Z2, R.� �----.- Date: J FINAL INSP TION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: /� i� s — r.cam { G=s . �'►�Gl rr 0 Of a,42 Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com .J . The Commonwealth of Massachusetts z Department of Industrial Accidents .;. d 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNHTTING AUTHORITY. Applicant Information p Please Print Le ibl Name (Business/Organization/Individual): Qz V C Address: billn b�� City/State/Zip: �� Phone#: U ✓� `��� Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer withemployees(full and/or part-time).* 7. 0 New construction 2UI am a sole proprietor or partnership and have no employees working for me in 8. emodeling any capacity.[No workers'comp.insurance required.] 9. temolition3.F1I am a homeowner doing all work myself[No workers'comp.insurance required.]t9. 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.F1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs 6.F1 We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.❑Other 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. i 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 workeis'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. m G Insurance Company Name: K Policy#or Self-ins.Lie.#: Expiration Date: 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un the ains nd Iti peijuty that the information provided above is true and correct. Si nature: 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 2.1Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i. N 'a 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 foi•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 v 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 bum 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 1 . i'� ------..,--- " �MONWEALr HOFUSE ISSUES I ""I ANS TFiE FOLLOWI:4 AS A ::REG JOURNEY LLC YOUNG . .. .:. MAN ;ELECTRIC aN MIRO SON ELECO ETRF;C �XF;`ia `rel LAV MLAOy 2 BLOSSOM UR'* COPY 32426:» MA o 1801_ � 51db ;> 0 /3.1/1.6 � 90 GOMMOLTH OF MASS AACHUSETTS eQA fl . C I ANS 15SUES THE ;FOLLOV�(NC Ri;1STERED MASTER LICENSE ELECTRIC --AN 1W . a OUNG:� SON ELECt ' 05LAV S R!C CO MLApY 2 BLOSSO �M S T � } Jr �. �`� y z wo'aJRN ffr! t ��� jui MA o 1801-5106 13847: 39013 Y Date... .......... NORTH TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING CHU This certifies that i 'S c� J �' has permission to perform ..... ........ ......................-170..... ............ ......... 1).. .... . . wiring in the building of.......e, ...... 9 4........ I................................. at ...... ..... . ............ .....................North Andover,Mass. ..... ............. Fee.ZV5........Lic.No. I.................................................................................... ELECTRICAL INSPECTOR Check# M 2 Commonwealth of Massachusetts Official Use only Department of Dire Services Permit No. Occupancy and Fee Checked aM 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 MQ) 527 Wt 12.0. 0/ (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: Z w City or Town of: NORTH ANDOVER To the nsp ctor of Wires: By this application the undersigned gives notice of hi or her irate tion to perform the electrical wor described below. ZltA Location(Street&Number) Owner or Tenant Telephone No. Owner's Address Is this,permit in conjunction with abubujilding permit? Yes No ❑ (Check Appropriate Box) Purpose of Building �T�i� 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 thefollowing 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. Batter 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 Initiatin 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 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 Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value f Elec ical o� � (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE t0VVERAG& 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 pai .analties of perjury t at tIz n ormatio is application is true and complete FII3M NAME: LIC.NO.: Licensee: /, ignature LTC.NO.: (If applicable,enter "empt" ' e is rase nu in`�t/©� Bus.Tel.No. 97 Address: Alt.Tel No.. *Per M.G.L c.'147,s.57'-6f,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. i ❑ 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 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: , SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ r Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INS CTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: 1 Inspectors Signature: Date: FINAL INSPE ION: Pass EN Failed 0 L Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidents u a I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ase Print Le ibl Name(Business/Organization/Individual): Address: City/State/Zip: �e*/ Phone#: r Are you an employer?Ch*rtnership ropriate box: Type of project(required): All! am a employer withemployees(full and/or part-time).* 7, 0 New construction am a sole proprietor and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8• Remodeling 3.FJ I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10E]Building addition ensure'that all contractors either have workers'compensation insurance or are sole 11.F1 Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insu ance.# 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 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. i 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•Haat is providing workers'compensation insurance for my employees.' Below is the policy and job site information. , �^ Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: ' Job Site Address: K119 City/State/Zip: Attach a copy ofthe w�ers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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 t pains)andpenalties o!fzwriury Haat the information provided a ove is a an ,cor recd Si nature: Date: /V Phone#: Official use only. Do not write in this area,to be completed by city or town off cial. 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 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'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 cavy 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-NIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia % t DJ.2— .. . OF p►OR TOWN OF NORTH ANDOVER n PERMIT FOR WIRING SBACHUS� Thiscertifies that ....................................................................... ..................... ....................... has permission to perform Q moo=` r�i,ll wrongm�the building of...............................................`C'.......................................................... at ....................................... . . ........................................................North Andover,Mass. Fee Lic.No.` �( ELECTRICAL INSPECTOR Check 4t 4 �f1 Commonwealth of Massachusetts Official Use owl i Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07j (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NM ,527712.00 (PLEASE PRINT ININK OR TYPE ALL.INFORMATION) Date: 45 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 ectri )lAvorkdescribed below. Location(Street&Number) Owner or Tenants Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes Z No ❑ (Check Appropriate Box) Purpose of Building �,�,fJf�j� Utility Authorization No. - IF Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Servic I Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity " Location and Nature of Proposed Electrical Work: f GAY i 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- ❑ N-o—.oTEmergency Ligliting rnd. grnd. Battery Units No.of Receptacle Outlets /V 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 E] Municipal El Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of 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 Wiring: No.of Devices or E uivalent OTHER: �U Atiach additional detail if desired,or as required by the Inspector of Wires. /� k Estimated Value of Electrical Work: Lr (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO RA : Unless waived by the owner,no permit for the performance of electrical work may issue unless r 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: INSURANCEBOND ❑ OTHER ❑ (Specify:) X certify,under the,pains d Senlfies of perjury,thatpin ormation on s plic ion is true and complete. FIRM NAME' . i �s LIC.NO.: vp Licensee: Signature LTC.NO.: (If applicable,jer " xe pt' t t e e num eri , Bus.Tel.No.• Address: �i Alt.Tel.No.:0Y *Per M.G.L c. 14 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)[I owner El 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 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 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: , FINAL INSP ION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: — Date: ZA& DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com Z The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia � V fV� Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: f/ City/State/Zip: 4MZ�"hone#: Are you an employer?Checkth appropriate box: Type of project(required): 1)AI am a employer with employees(full and/or part-time).* 7. New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. F1 Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t �4.F1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.$ 13.FJ Roof repairs 6. F-1Weare a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. i 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-coniraciors have employees,they must provide their workers'comp.policy number. 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.Lie.#: Expiration Date: 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. Ido hereby certify under thepa* s a dqpaUleko erjtn that the information provided above is true and correct Signature: Date: G� Phone#: Official use only. Do not write in this area,to be completed by city os•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#: I 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 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,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 www.mass.gov/dia I T a MONwEALTH OF ® Migss sQA. ® N sErrs ISSUES �LiRaC'IANS 7F,E FOLLOWI:VC L I ,. AS A REG JOURNEY CENSE:.::. .:.;.. MAN ELECTRI YOUNG SON ELECT CIAN< W<, M1RpSLq RPC C f RN WOBtI r y 3242MA 0 6=; ;:<;:..;::<:;,...;:: 1801- � p7-/311 �. 39 p 12 £ f;OMMONyyEALrH OF e • ® • • ® MASSACHUSETTS; B.QAR ELECT IClANS 15�JES TNt FOLLOWING LICENSE 81;G1STEREQ MASTER E;LECTRdCL`AN W A y j4= ON ELECI?!C co >Jt �`. z A-V S MLRD'Y r� 2 BLOSSOM b f1 �V MA 01801-5106 07/31/16 . ..:39013 i 4 f Date/ZA�;- . °i I a :a NORrh TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING This certifies that.,,.�,...................r ..............Q�+ `"�e—` has permission to perform. P--SMT. y..�... � 14...7- plumbing in the buildings of.......0..0 (2. - .................................................................... at........ .............�-�.. ....................... North Andover, Mass. Fee ?....67....Lic. No. ....� .�. ... ..........................................................................:...... PLUMBING INSPECTOR Check# 4-12n Z (� 00-20 VI, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY/TOWN NQ&h, A NS0V f)Q— MA DATE l d12/15 PERMIT# JOBSITEADDRESSSO H&I'1 OWNER'S NAME /2C6 P OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL( EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION: REPLACEMENT`.❑ PLANS SUBMITTED: YES❑ NO FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM. DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN QQ FOODDISPOSER FLOOR I AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE IMOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES S WATER,PIPING OTHER INSURANCE COVERAGE: I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY ❑ 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. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be 4comance with all Pertinent ro 'Sign of th-6 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'SNAME , ` Aj C gf/-A � LICENSE# J SIGNATURE MP❑ JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME _ai9/ & 6e&AJ!C _Yc�f� ADDRESS 1V JI CITY STATE IU)" ZIP 6�?0 7Y T FAX CELL 97a`"y.3"A,69`V EMAIL e,- 1-? L'-e r 10 Y The Commonwealth of Masso chuselts Department of IndustrialAccidents X Congress Sheet, Suite 100 Boston,AIA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): FF/v C �� Address: r C�( e City/State/Zip: /t/�`� D Phone#: 9 y d 3 769 y Are you an employer?Check t&appropriate box: Type of project(required): 1.❑I ama employer with ! employees(full and/or part-time).* 7. ❑New construction 2 I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling !!CC any capacity.[No workers'comp.insurance required.] 9, El Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.2kPlumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 14. Other 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 0 152,§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. f 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-coritractors have employees,'they must provide their workers'comp.policy number. I am an employer that is pioTe ' g workers'compensation insurance for my employees.'Below is the policy and job site information. ter. / /� � Insurance Company Name: r�� �y� v Policy#or Self-ins.Lic.#: Expiration Date: 7 Job Site Address: IA- 61 , 1 re e f City/State/Zip:.—A /�Z ( � \Attach a copy of the workers' compensation policy declaration page(showing the policy number an expiration date). Failure to secure'coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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 penalties of perjury that the information provided above is true and correct. Date: / o1 l a,� � 5 Si nature: • Phone#: 97 y `�76 Y Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permrt/L icense# 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#• 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 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 o COMMONWEAL.H OF MASSACHUSETTS 1 BOARD OF i PLUMBERS AND GASF.ITTERS SSUE:S THE FOLLOW I N:G >_I CENSE Q; MANfPLt'MBER L I CE9IS:ED. AS A J.;O:UFNY ,. `tip a JA.ME.S P GREENE. . � 1 � Lu Z + 4 BRII7GE ST '+„ SALEM 03679 32,73, i S r Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost IS W6,,934.0:01 $ - $ 7,307.21 Plumbing Fee $ 913.40 Gas Fee 100 comm. $; 1O:GO, Electrical Fee $ 913.40 Total fees collected $ 9,234.01 50 High Street 700-2016 on 12/8/2015 Build Out on Floor 1,2,3 3 j D B-2 S Z