Loading...
HomeMy WebLinkAboutMiscellaneous - 519 FOREST STREET 4/30/2018 (2) 519 FOREST STREET 210/106.6-0008-0000.0 T> d NORTH ,{ TOWN OF NORTH ANDOVER 1 4 PERMIT FOR WIRING SSACMUSE� This certifies that ............... - L ir,f �-.z has permission to perform wiring in the building of...... ........... at.............:.............�°-�:-.{'-�'............................... ... ,North Andover,Massa Fee`— $�........ Lic.No:3I--44 . ✓�........ ,,<- ... LECTRICALINSP Check # �f 8295 Commonwealth of Massachusetts Official Use only '-} = Department of Fire Services Permit No. 90" 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 IN INK OR TYPE ALL INFORMATION) Date:_g �-/�1—eC7 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) Owner or Tenant j©tip 4,6 Z*0_ gl• Telephone No. 57 Af '0�X Owner's Address Is this permit in con unction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building t��,� Utility Authorization No. S/9 00.46 Existing Service 166) Amps 102U /n7 yCIVolts Overhead Undgrd ❑ No.of Meters New Service aOD Amps fyD l,c yfJ Volts OverheadZ 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 CeilSusp.(Paddle)Fans No.of Total : Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above .rnd. ❑ rnd. ❑In- oBatomergencyigg te_ 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 Tons g 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 Water No.of No.of No.of Devices or Equivalent Heaters KW Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Elparical Work: f�Dfa, (When required by municipal policy.) ,.' Work to Start: 611jrl4S Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C GE: 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: INSURANCE V_ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the in ormatioR on this application is true and complete. FIRM NAME: Aj 6Le4 )5' LIC.NO.: .s���/3/— Licensee-��y&-j_ L_( 5� A2 Signature LIC.NO.: ' (If applicable, e}�er.,, exempt 11 in the license n mber / � // Bus.Tel.No.: 9l�-?�� ?�f Address: "exempt 'Y SZ �t c� '�'OrCf /�'./7f Alt.Tel.No.:Sa �-zC-S"3.2- Z, *Per M.G.L c. 147,s. 57-61, security work requires Department of Public Safety"S"License: Lie.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. �� �' The Commonwealth of Massachusetts w.� Department of Industrial Accidents .a Office of Investigations 600 Washington Street Boston; MA 02111 www.mass,gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print'Legibly Name (Business/Organization/Individual): Address: — S S f City/State/Zip: K—dle,k'0J IV14 Phone #: 9 28 - �7,r;17 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2Piam a sole proprietor or partner- listed on the attached sheet. $ 7 ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their IO�Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other 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 their workers'comp.policy information. 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. Lic.#: 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby ce cfy un er the pains and p lties of perjury that the information provided above is true and correct. Signature: -/y h r� Date: —Q v Phone#: <9 7 6� — /�/ — 3,12-2-1 Official use only. Do not write in this area,to be completed by city or town official, City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: To C ' Mme.` U� FO&ES7- sr— Ct-mtu-j �:7We_ P FORM OF NOTICE OF CASUALTY LOSS TO BUILD . UNDER. MASS. GEN. LAWS CH 139 SEC. 3 MAR 2093 Uj TO: BUILDING COMMISSIONER OR BOARD OF HEALTH OR NORTH ANDOVER INSPECTOR OF BUILDINGS BOARD OF SELECT OFFICE OF TOWN MANAGER North. Andover Town Hall. North. Andover Fire Department 120 Main Street ADDRESSES 124 Main Street North Andover, MA 01845 North Andover, MA 01845 ATTENTION: FIRE PREVENTION RE: INSURED: DePACE, Anthony & Linda PROPERTY ADDRESS: 519 Forest Street ----------------FL North Andover, MA 01845 POLICY NO. PGP 7033133-04 LOSS OF Water Damage on March 18, 2003 FILE OR CLAIM NO. DJ0303046A CLAIM HAS BEEN MADE INVOLVING LOSS, DAMAGE OR DESTRUCTION OF THE ABOVE CAPTIONED PROPERTY, WHICH MAY EITHER EXCEED $1,000.00 OR CAUSE MASS. GEN. LAWS CHAPTER 143, SECTION 6, TO BE APPLICABLE. IF ANY NOTICE UNDER MASS. GEN. LAWS CHAPTER 139, SECTION 3B IS APPROPRIATE, PLEASE DIRECT IT TO. THE ATTENTION OF THE WRITER AND INCLUDE A REFERENCE TO THE CAPTIONED INSURED, LOCATION, POLICY NUMBER, DATE OF LOSS AND CLAIM OR FILE NUMBER. SIGNATURE a fre eger T.M. SEGER CLAIM SERVICE, INC.. 459 Washington St - PO Box 277 - Duxbury, MA 02331 Telephone (781) 934-9770 Fax No. (781) 934-9194 ON THIS DATE, I CAUSED COPIES OF THIS NOTICE TO BE SENT TO THE PERSONS NAMED ABOVE AT THE ADDRESSES INDICATED ABOVE BaPI LASS MAIL. __ 03/27/2003 & DATE Ch-a7i e E. Seger, Secretary FORM 13 (5-1999)