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HomeMy WebLinkAboutMiscellaneous - 524 JOHNSON STREET 4/30/2018 (2) 524 JOHNSON STREET 210/038.0-0025-0000.0 I PORT" O�t,�a° ••1ti °0 TOWN OF NORTH ANDOVER p PERMIT FOR WIRING SSACMUS� This certifies that /� '�E2 ......... �.�' ..................... `. .............. has permission to perform ...... �L� 2 ........ ......... .......................................... wiring in the building of................. O2.T. ....................................... at.........SL...`....1...;T.a....�....`..v....S...4......-.r...�.........S...i...".. .. North Andover,Mass. Fee....�:�......... Lic. No 4qf 7..................... . ... ............. ..........� ',/�� ELECTRICAL INSPECTOR / Check # C;�r9 7 j 7704 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No.Oc BOARD OF FIRE PREVENTION REGULATIONS [Rev.l 07]upancy and Fee Checked 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: /0 ,?-Q 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 i/-��1e� d- nd ��G�'y� Telephone N 077 K Owner's Address Sel k--7 f- Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Boa) Purpose of Building .orUtility 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: w Completion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers A No.of Luminaire Outlets No.of Hot Tubs Gener ors KVA No.of Lun6aires Swimming Pool Above ❑ In- ❑ o.o rgency Eig g , rnd. rnd. Batte Um No.of Recepth Outlets No.of Oil Burners FIRE AL o.of Zones No.of Switches No.of Gas Burners / No.of Detec on and InitiatiAL,Devices No.of r ges No.of Air Cond. TotaTonal No.of ming Devices No.o Waste Disposers eat Pump Number Tons No.01,s5e -Contained Totals: Detection/Alerting Devices— No./of evicesNo.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection N/0.of Dryers Heating Appliances KW Security Systems:* Devices or Equivalent No.of Water No.of No.of Heaters KW Signs Ballasts . DataNo.ofitinDevices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP elecommunications Wiring: No.of Devices or E uivalent 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: /D`?'0.-? Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury, that the information on this application is true and complete, FIRM NAME: U!'t pS 11�*✓� �cG° , Act vl LIC.NO.: �4L'/7 Licensee-,1-_0'_/1'1 h-4/ZA/ Signature—,.7. LIC.NO.: (If applicable, enter"exempt"in the license numbe line.) Bus.Tel.No.:6/7-?7(1— Address: ._A�_7 �G'( "A// 37, cclks�/- .90 r/�S/6%h M 71 Alt.Tel.No.- ` *Per M.G.L c. 147,s.57-61,security work requires Department of Publi 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 Signature Telephone No. PERMIT FEE: $ f 4 t �� - 0 7 w. h r ' The Commonwealth of Massachusetts fl-I Department of Industrial Accidents lJ Ogee of Investigations iq #► 600 Washington Street iJV. Boston, MA 02111 www.nuus gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Piumbers Apolicant Information Please Print Leaibty Nanie(Business/Organization/Individual): 7kj,?O j' IqA e-r h Address: /3-7 wa'r4l[� 11 s/ City/.State/Zip:" - 61S fOv► #• Are you an employer?Check the appropriate box: Type of project(required): 1.F1 am a employer with 4. ❑ I am a general contractor and I 6 ❑New construction 2`4 employees(full and/or part-time).* have hired the sub-contractors 1 am.a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These subcontractors have S. ❑Demolition working for mein any capacity, workers' comp.insurance. q, ❑Building addition [No workers'comp, insurance 5. ❑ We are a corporation and its ` 10.❑Electrical repairs required.] officers have exercised their rep rs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MOL I I.❑ Plumbing repairs or additions myself. [No-workers'comp. c. 1.52, §1(4),and we have no 12.❑ Roof repairs insurance required.]t .employees. [No workers' comp. insurance required.] 13.❑Other *Any applicant that checks bort#I must also fill out the section below showing their workers'bompensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then him 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-mtractors and their workers'comp.policy information. I am an employer that is providing workerscompensation insurance for ray employees: Below is the policy and job site information. i Insurance Company Name: ' Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip.- Attach ity/State/Zip:Attach a copy of the workers'"compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500,00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert' tier the pains saand pen 'es of perjury that the information provided above eiis•true and correct Si afore Date: Phone 2 2 -5—Y,9 [[Official only. Do not write in[his area,to be completed by city or town official n: Permit/License# hority(circle one): Health 2. Building.Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector son: Phone#• 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 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 numberlisted below. Self-insured companies should enter their self-insurance-license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed iegibly. 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 bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-977-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Date.. /© . . .. . . . ... .. r" NORT1y 1.Yp .' I 3r �` TOWN OF NORTH NDOVER ' PERMIT FOR GAS INSTALLATION SACMUSEtt This certifies that . . . .Vi`''e . . . ;✓.� -f '. "-' . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . <! ? !. . in the buildings of . . . . . . . . . . . . . . . . at .` .. . . �. �}� <^ 'r� . . . ( , North Andover, Mass. Fee`.`'.' .. . . Lic. No� k . . = . . . . . . . . . . . G GAS INSPECTOR Check 6176 MASSACHUSETTS UNIFORM APPUCATON FOR PERNUF TO DO GAS FITTING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations A> 404, ,r d 7' Permit# Gl 76 ; Owner's Name Amount$9_ New Renovation Replacement Plans Submitted W C � H a .. F, z � $ z H IW- z Q x W a W W W F x z d w z m 'z p C o x 3 c .da u ooc > c a F o SUB-BASEMENT BASEMENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR Et= I 4TH . FLOOR STH . FLOOR 6TH . FLOOR 7 T H . F L O O R 8TH . FLOOR (Print or ty )_ ' Name ?Z / � Check one: Certificate Installing Company ElCorp. Address �� y�--- ElPartner. PW C-v--A Business a ep one y-7 .� 7 7 Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance,policy or it's substantial equivalent. Yes No13 If you have checked Les,please i dicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 13 Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 13 I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By: Signature of Licensed Plumber Or Gas Fitter Title 13 Plumber --J^1 z1.-- City/Town Gas Fitter License Number OMaster APPROVED(OFFICE USE ONLY) Journeyman