HomeMy WebLinkAboutMiscellaneous - 534 BOSTON STREET 4/30/2018 / 534 BOSTON STREET
J 210/107.D-0081-0000.0
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4 Date..1 �44...............
OF p&0RT/1
3?•._ ao� TOWN OF NORTH ANDOVER
' PERMIT FOR WIRING
CHUs�`S
This certifies that R"C,�Cj
.......................................................................................................
has permission to perform ....^ ..,G..�..... .yt. 'P
wiring in the building of...................... -�►. VY
....................................................................................
,�j_,` Gam[
at ........ ?—a ...... ` ^�........ .: ...... , orth Andover,Mass.
Fee.. 5.... ".....Lic.No. .G�...+,o.. ��
.............................. . .. . .. .... .
ELECTRICALINSPECTOR
Check# zuc�7
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9 `7 9
Commonwealth of Massachusetts Official Use Only
t 1? 1'I
Department of Fire Services Permit No.
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev.1/071 (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 INMK OR TYPE ALL MFORMATIOA9 Date:
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or he intention to perform the electrical work described below.
Location(Street&Number) j�� JS.. (/
Owner or Tenant d 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. J,f O C s o,
- Existing Service /U c Amps / Volts Overhead Q Undgrd❑ No.of Meters / C9 G,
New ServicAmps / Volts Overhead Undgrd ❑ o.of Meters l
Number of Feeders and Ampacity
Location and Nature of Proposed EIectrical Work: �a+,G. I VX Se U I
OF ompletion 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
Above In- o.o Emergency Lighting
No.of Luminaires Swimming Pool rnd. 1:1rnd. 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
Tons
No.of Waste Disposers Heatpump Numb_er 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 E uivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wtres.
Estimated Value of Electrical Work: L L (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties ofperjury,that the information on this application is true and complete s/�
FIRM NAME: _ LIC.NO.:Z 1=
Licensee: P6 C krn.*- C\iyh ,�t' Signatur °_ LIC.NO::
(If applicable,enter "exempt"in the ljcenseinzumber line) _ r Bus.Tel.No.:
Address: 1 1 1 -�✓I2 ►.� Z /., Q �13 G Alt.Tel.No.: ct 2 i7 7 0 6 ti
*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:$ rj
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 D �'
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[N 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 0 Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
ROUGH INSPECTION:
Pass R Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
FINAL INSPECTION:
Pass f oe Fail Ryf4pecthe4lquired($.) ❑
Inspectors Comments: —1 _ /
Inspectors Signature: Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
1{
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The Commonwealth ofMassachusetts
Department oflndustriglAccidents
Office of Investigations
600 Washington.Street
Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance.Affidavit: Builders/ContractorsfElectricians/Plumbers
Applicant Information Please Print Le 'bl
Name(Business/Organization/Individual): � CLA� (N-VA-1 CIA
Address:
City/State/Zip: �/� Phone#: /-Z
Are you an employer?Check the appropriate box: Typo 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
7. Remodeling
2.P I am a sole proprietor or partner-
listed on the attached sheet.
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
officers have exercised their 10.❑Electrical repairs or additions
required.] o
3.El am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),andwehaveno 12.❑Roof repairs
insurance required.) employees.[No workers'
13.❑Other
comp.insurance required.)
*Any applicant that checks box#1 must also fill out the section below showingtheir workers'compensation policy information.
i Homeowners who submit this affidavit indicating they tie doing all work and then hire outside contractors must submit a new affidavit indicating such.
1Contractors 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.Lie.#: Expiration Date: I
Job Site Address: ` dzf�n J ( City/State/Zip: 4
;;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 fonm 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby certiounder the andpenalties ofperjury that the information provided above is true andcorrect. -
Signature: Date: 2p 6 u L.
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.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other - -
f'nnta rt l�Prsnn Phone#:
.r
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c. 143,§3L,the 4 t
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed J
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 maybe 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 conceming the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012.
❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑
❑Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass EN Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass 0 Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
r
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass 0 Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
ROUGH INSPECTION:
Pass 0 Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
FINAL INSPECTION:
Pass IN Failed Re-Inspection Required($.)❑
Inspectors Com
Inspectors Signature: 0 Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
,q�COMMONWEALTH OF MASSACHUSETTS
s s a
JA a
BOARD OF
UftTRI C I ANS I
I SSUE.S TIE FOL LOWING `L I CENSE
AS 'A REG JOURNEYMAN ':ELECTRICIAN
A1CHARD RAIMOND .
X111 PERKINS ST cwl
IAPT 286' ' J_a
JAMA I C`A PlA<I;:N . MA -4.339 I
51180917
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Date......../..".....................7
Ot NO oTM 1ti
3? �•,�•``•.•+•-•s�o� TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
SS�cMue� '
f
Thiscertifies that ................��.. .....................................................................
.SEIi-• s ys,�-,�
has permission to perform .........
is
............................... ................................
r wiring in the building ofT k f '41
L
............................... ........ '.� .................................
`S..y �.f7d7L S7 .
at..... . . ... ....................................................,North Andover,Mass.
I~ee. s............. Lic.No .............�
........................ .I . ....... ..........
ELE ICAL INSPECTOR
Check #
7635
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. -2�� gs--
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: 9-/o?—o a
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) ,534- gos�pd SfrzQ�f
Owner or Tenant 1h0md,5 PQ - rr4 h Q Telephone No.
SA
Owner's Address e
Is this permit in conjunction with/a building permit? Yes E] No (Check Appropriate Box)
Purpose of Building bw e 1/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: Lc�irzc �P.p/-e i ,pGttvlpt �o � " ?ems
r�na� A/�yM e!j JQ/
f
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 Emergency Lighting
rnd. rnd. Battery 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 Disposers Heat Pump I.Ny.m.4-er Tons J.K.W 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 , No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP ��G Telecommunications Wirin :
No.of Devices or Equivalent
nt
OTHER:
F 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: 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 ins and pen flies of erjury,that the information on this application is true and complete
FIRM NAME: AV Id EQ G(YI LIC.NO.: XIR46ff
Licensee: SAMC Signatur LIC.NO.:
(If applicable, enter "ex mpt/",in the lice a number li ) j Bus.Tel.No.: f'- 6 '�o
Address: ��td�G2Ve�V� rQ,ea,�- Alt.Tel.No.:6-2E-53? �ol�
*Per M.G.L c. 147,s.57-61,security work requires Depart4ient 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.