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HomeMy WebLinkAboutMiscellaneous - 54 Harold Street 56 HAROLD STREET 210/010.0-0006-0000.0 I • Date... 1 of° `;ro°TN •"°°� TOWN OF NORTH ANDOVER ' ' PERMIT FOR WIRING ,SSACMUS� This certifies that ........ ........ .. . e L R)9 Al ........�............................ ......................... has permission to perform .7 .......................................... i �P wiring in the building of..........Z-...................M...................................................... at ........ ,North Andover,Mass. _ 2 Fee......S............... Lic.No..'. -�'. pt....... . ........ ELECTRICAL INSPE R Check tl 10722 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,-,' ingoing construction activity,and may be.deemed.by the-In9pector_ofWires abandoned-and-invalidlf_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. ule 8—Permit/Date Closed: Note:Reapply for new per 0 Permit Extension Act—Permit/Date Closed: Official Use Only Commonwealth of Massachusetts - Department of Fire Servlces PemutNo. 107 -2— BOARD OF FIRE PREVENTION REGULATIONS [Rev.1 1 y and Checked . (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),527 CMR 12.00 (PLEASE PRINT XNINK OR TYPE ALL INFORMATION) Date: o 1 City or Town of: NORTH ANDOVER To the Inspectorof Wires: By this application the undersigned gives notice of hi or her intention to perform the electrical work described below. Location(Street&Number) C6 � J(I f�`�� st Owner or Tenant 4�c�,� �S; --� Telephone No. Owner's Address -'�t7Co 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: A O Com letion o the ollow* 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- ❑ Ao.ot"Emergency.Lighting rnd. rad. 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 InitiatingDevices No.of Ranges No.of Air Cond. Tons l No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-contained Totals: ••'�•*•W'•""""" """' Detection/Alerting Devices No,of Dishwashers Space/Area Heating KW Local❑Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:Y• No.of watero. No.of Devices or E uivalent t Heaters KW No.Si Bal as Data Wiring: Signs Ballasts No.of Devices orE uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: ent r No.of Devices ox E uival OTHER: Attach additional detail ifdesired,or as regzilred by the Inspector of Wires. Estimated Value of lect ical Work: 1 goo (When required by municipal policy.) Work to Start: 01 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 liHBONDE] ' surance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cis in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OTHER ❑ (Specify:) X certify,under th ains and penalties ofverjYrZ,that the information On this application is true and con pl'ete. FIRM NAME: A,Qfg-,,,- �L` LTC.NO.- Licensee: C�l�Fsz��. Signature LIC.NO.: 23� (Ifapplicable,enter"ex pt"in the license irmberline. BuS.Tel.No.• /�-- Address: R?L �� �Zt Yck *PerM.G.L c. 147,s.57-61,security work requires Department ofPublic Safety"S"License: Alt. Lic.No. i32�36 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:,$ i r , E C ' 1CCAJG 3w8marOR�s' 1.B•OUG f. C7C oN: �'�ssec�•-, �'a�tefl--j � fie-inspection z'eciuixecT($50.OQ)�X j 3inspectvxs �camxtte�afs: - ', (. mm ee re signature-AO Tnitiais) Pate Passea� [ ) iaiTec7--r J e xns�ection xee�uixect($50.00)-[ Inv ecton,Comments: QCxzs 'actors,Pignature•-xio mmais) date a 3.UNDERGROUND I NS'ECTXO.N. , 3'assed—[ ] X+aileci--j ?�e••inspectionrequired($50.00)- f J i Inspectors'ew m.ents: ' Cnspectoxs',�ignature-no initials) Pate 4-WSIlECUON--sEB'VXCE: .DMA.I CAILUR D N ±ONAE G9 i i : NAME:. Passed--[ I Re-inspection required($50.00)-[ � Inspectors'cowm.eA:js: ' v (Xtisp actors',gigaature-uo wtiais) pate or �•XN�'EC�'XOli7-•4T�R: '.Re lnspactionxequired($50.00)•-[ �s�ectoxs'col-tMents: �L�sp actors'signature xto xnitiais) date 1)0OR T'A.GO M TO BE 1+XGT,E1 OUT AO LEFT ON RITE W M.A XA TO BE EWSTEGTED Y NOT The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information c Please Print ULAN Name(Business/Organization/Individual): Address: `"T�eN�_OA City/State/Zip: r P V" kk DOM Phone#:_9 f 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. E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. ElWe are a corporation and its required.] officers have exercised their 10.E]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. I Homeowners who submit this affidavit indicating they ace 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. lam 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. I do hereby c r ' under th p and penalties ofperjury that the information provided ab vel true and correct. Sinature: �J !�� -- b -- Date. . 1 l I2 Phone#: <0 Official use only. Do not write in this area,to be completed by city or townofficial. 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-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 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 Depadment of Industrial Accidents Office of Investigations 600 Washington Street Boston}M,A.02111 TO,#617-727-4900 ext 406 or 1-877"S.A.FE Revised 5-26-05 FaY,#617-727-7749 wWW.Mass.govldza Location No. Date NORT►� TOWN OF NORTH ANDOVER O.t`�•• •1�G A A Certificate of Occupancy $ Building/Frame Permit Fee $ ,ssACMUSE�� Foundation Perm' e $ Other Permita (pcd6 $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector �p 205 Div. Public Works PER.ItiT NO. 6 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP K40. LOT NO. 2 RECORD OF OWNERSHIP ;DATE BOOK PAGE ZONE I SUB DIV. LOT NO. ; LOCATION, PURPOSE OF BUILDING OWNER'S NAME jH �U�! /'� NO. OF STORIES SIZE OiW IER'S ADDRE S /w 7 ,p,(] L bjIS!/� BASEMENT OR SLAB ARCHITECT'S NAME\7 (r ` 1���" SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME T1,M 1 j , 4a11 '7'',ppr/� SPAN DISTANCE TO NEAREST BUILDING V-/q'6,/ ////V'/ DIMENSIONS OF SILLS DISTANCE FROM STREET � POSTS DISTANCE FROM LOT LINES-SIDES REAR " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW 0 SIZE OF FOOTING x IS BUILDING ADDITION No MATERIAL OF CHIMNEY IS BUILDING ALTERATION a/�s IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM 0 REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS j 3 PROPERTY INFORMATION �'-X,01-c 77/7-, /c c7e Gam' f LAND COST SEE BOTH SIDES I 14r- EST. BLDG. C V / j/�+ �G p' G PAGE 1 FILL OUT SECTIONS 1 - 3 / EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 sG �Gh EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED `'�� a. �/— A5--- en--4 WEzLelUILDING INSPECTOR SIGNATURE OF OWNER OR AUTHORIZED A N } F E E ^ C� OWNER TEL.# PERMIT GRANTED CONTR.TEL.# 19 �Lt) CONTR.LIC.# ced H.I.C.# O BUILDING RECORD 1 OCCUPANCY 12 ' r SINGLE FAMILY _ SiORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION I 8 INTERIOR FINISH CONCRETE _Ill 3 1 2 13 CONCRETE BL K. PINE BRICK OR STONE HARDW D —_ i —PIERS PLASTER DRY VJAIL _ UNFIN. 3 BASEMENT 11 AREA FULL FIN. B'M'TAREA _ '/. 1/1 1/ FIN, ATTIC AREA _ NO BMT FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE WOOD SHINGLES EARTH _ ASPHALT SIDING HARD\!J'D _ ASBESTOS SIDING _ COMMCN VERT. SIDING ASPH.TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I� POOR _ ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE HIP BATH )3 FIX.) _ GAMBREL MANSARD TOILET RM. l2 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ 1 TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st _1-3rd NO HEATING NORT {4{ Town of �.. _ - over 0 II y No. 158 Arc-iL Zr" 19`tr o ` L A Kr '° dower, Mass., A- COCHICI WICK YL�I "7� ORATED P" E BOARD OF HEALTH ERMIT T Food/Kitchen Septic System + •_ BUILDING INSPECTOR THIS CERTIFIES THAT �V�.......�'�°t'!�t'!�� - ..... ..... .............................. ......................................... Foundation has permission to erect...�C1.k'f'9� ................. buildings on...a ... t�A Rol.4....... .......... Rough t0 he{OCCUpled 8s....�«►�K.LQ... 4��. .1�?or ...4,4.4 .... �.�.�...J� �....... .. � Chimney provided that the person acce tfn this permit shall in every respect conform to the t�ms of the application on file in p p p g p Final this office, and'to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of t Buildings in the Town of North Andover. PLUMBING INSPECTOR c VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final p±; PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR, . .... UNLESS CONS TR C Rough ... .. Service arABUILD2ING INSPECTOR Final a � Occuparwy Permit Required to Occupy Building GAS INSPECTOR Disla ,in a Conspicuous Place on the Premises — Do Not Remove Final ugh p Y P Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT ► Burner PLANNING FINAL CONSERVATION FINAL street No. 4 Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT Town of North Andover BUILDING DEPARTMENT ` Homeowner License Exemption (P'_e..se print ) NL'umce_ St_ee, _ Address Sec _ion of tc'•� 42 �a:-,` Home Phone Wor:. ?!-.one V'j State Zip ccc= "homec,.,;ners" was extended to include or six un- -s or Less and to allow such homecwne_� t _ an n _c..�_ for hire who doEs not possess a License . prc' cne oNe .,_ ac _ as su_er*iisc_ . (State Build-ns Cc _ ode , Se,: -.Lon ,. rho o,ti^ a par..a1 or Land on which he/shoe reside_ or in __n ._ tle_e is , or is in --ended to be , a one to s _x E`7-_ d'.. �. - a= :a r-:-, or de_ached s truc ..oras accessor , to such use_ at:u %r ar... A oEr_on w'r,o cons truC _s more than one home in a twc- . -n- 0E L _ :i.anc - be consiCereC a homEowner . Such "homEownEr" _C ...c 3uIC_. 0i= _c4aL , on a form acCepLable to the BuLe_n, Ut _ _ - • sn e sn, DE ' es-ons _b1E ic_ all such worX OEr_orme'- —c••vnEras. .:';E= resvons_b'_-- .' for cc - - - - - D"- O � E= Ln e., s unCcr_ _aG� t..= PrCC�C sa:.d prccad-_ _� OFFICES OF: pt ' Town of 120 Main Street • North Andover, APPEALS NORTH ANDOVER BUILDING �'*�::„- Massachusetts O 1845 CONSERVATION "" DIVISION OF (��l . HEALTH PLANNING PLANNING &. COMMUNITY DEVELOPMENT KAREN H.P. NELSON, DIRECTOR �ZO I. 1v� • In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit Number t S—�R is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S 150A. Tete debris will be disposed of in: /�� x or (<- LL,1 41 ✓ (Location of Facility) Signature [Arinitpplicant 7 �a�~ __ 1/ .zG hl -WDate NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. Date 7/?. ".� go7:�ti, TOWN OF NO TH ANDOVER PERMIT FOR PLOMBING ,SSACHUSE� � n This certifies that . . . . . . . .Z. s . . . . . . . . . . . . . . . . has permission to perform . . . 44 . �. ? . . . . . . plumbing in rt/he buildings of . f �.11?� �.� '^. . . . . . . . . . . . . . . . . . . at . . 5-4.. . #14/.t P.4 .� . . . . . . . . . . . . . . . . . North Andover, Mass. i Fee . . . . .Lic. No.3 L �.'. . . . . . . . . . IUMBING . . .�.--^--(^ �-�,. . . . . . INSPECTOR Check # 232 7 7765 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS / Building LocationlJoq o �� ? t r � ) Owners Name /� ��0 yt ,/� Date�" Pemut#_�7 -- —�— Type of Occupancy Amount New 13 Renovation Replacement "� Plans Submitted Yes El No El FIXTURES U C co A or 4 04 MFLOaz 3MFLOCILZ 4MFLOCR MFLOaa —+ I sI1FIHIM MFLOCR (Print or type) Check one: Installing Company Name (J✓C O r D�y ` Certificate dd �orp' Address �© ��, its C 4r� S �`T— J? 11 Partner. Business elephone Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking theappropriate box: Liability insurance policy Other type of indemnity Bond Insurance Waiver: I,the undersigned,have been made aware that the licensee ❑ three insurance of this application does not have any one of the above Signature Owner ❑ ❑ Agent 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 Massachusettste P b. e�andCh�apter 142 of the General Laws. By: igna ure o ense um e Title Type o lumbing License City/Town 7 icense um er Master Journeyman El (OFFICE USE ONLY Date..... ........................ NORTil { °f'"`°:•�"° TOWN OF NORTH ANDOVER PERMIT FOR WIRING SSACHUS� J t Thiscertifies that ..........................................6",............................:...................... has permission to perform A... .ng in the building of................................................................................... r S r� �l ��c at...................... ...........� ........5. ................... ,North Andover,Mass. [76 Fee.. , "". Lic.No..J..2j.q �i- ........ ..'� ...C�!4Gf... ELECTRICALINSPECTOR Check # i 8 2 4�; Rom-N Commonwealth of Massachusetts Official use only r Department of Fire Services Permit No. Z. 4 L BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WO All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 RK (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER By this application the undersigned gives notice of his or her intention to perform the To the Inspector electrical workies described below. Location(Street&Number) Q Owner or Tenant Owner's Address 9- (, Telephone No. Is this permit in conjunc on with a building permit? yes Purpose of Building rr El NO E] (Check Appropriate Boz) ''"�f!t Utility� ty Auth�rizifon No. Existing Service Amps / Volts Overhead New Service Amps El Undgrd❑ No.of Meters / Volts Overhead ❑ Undgrd ❑ No,of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Com letion of the followin table may be waived bv the Ins ector o Wires. No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans No.of Total No.of Luminaire OutletsTransformers KVA No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- o.o mergency ig g Abd. d. Batte Units No.of Receptacle Outlets :N:o�. Of Oil Burners FIRE ALARMS INe. of Zones No.of Switches No. of Gas Burners No.of Detection and initiating Devices i No.of Ranges No.of Air Cond. Total Tons No,of Alerting Devices FofDryers Disposers eat Pump Number Tons _ KW No.of Self-Contained Totals: Detecfion/Alertin Devices shers Space/Area Heating KW Local❑ unicipal Connection ❑ Other Heating Appliances KW Security Systems:* No.of Water No.of No.of Devices or E uivalent Heaters KW No.of .Data Wiring; SWyns Ballasts . No.Hydromassage Bathtubs No.of Devices or Equivalent g No. of Motors Total HP Telecommunicationswiring: OTHER: No.of Devices or Equivalent q�,l Attach additional detail if red, or as required by the Inspector of Wires. Estimated Value of Electrical Work: / v (When required by municipal policy Work to Start: S Inspec ' ns 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 cove a is in force,and has exhibited proof of same to the permit issuing office.. CHECK ONE: INSURANCE In BOND ❑ OTHER ❑ (Specify:) I cerWfy,under ihe pains andpenalties o er'ur1',that the information on this application is true and complete- FIRM ! F RM NAME: Licensee: LIC.NO.: — -� ��• ,� Signature (If applicable, enter"exempt-in the license number line.) LIC.NO.: f2 S Address: 3 /(J c`C It oal r S^h c�y�46� y, Bus.TeL No.: �*Per M.G.L c 147,s 57-61,security work requires Dty Alt.Tel.No.: OWNER'S INSURANCE WAIVER: I am aware thattheLicense does not Safehave,the liability Lic.No. required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑ownerco�wnormally e rm gent Owner/Agent Signature Telephone No. PERMIT FEE:$ i i I l e �r tr (� ' b The Conwwn wea th of massachusetts kj r! Department of Industrial Accidents IA ' Office of Investigations . f 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Inshrance Affidavit; Builders/Contractors/El AIicant ectricians/Pinmbers Information Please Print Lezk Name(Business/Organizafion/individual)' Address: City/state/Zip: 01P01PK Phone #: Are y n employer?Cheek the appropriate box: 1-0 I am a employer with 4. I am Type of Project(required): ❑ a general contractor and I employees(full and/or p -time).* have hired the sub-contractors 6• ❑New construction 2. I a . ❑ m.as ole proprietor or partner_ listed an the attached sheet 7• ❑Remodeling ship and have no employees These: sub-contractors have 8. working for me in an aci workers' comp.insurance. 9. ❑Building n y� h'• 9. Building [No workers'comp,insurance 5. ❑ We are a corporation and its . ❑ �addition J 3.0required.] officers have exercised their 10.❑Electrical repairs or additions Iain a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions myself.[No-workers'comp. c..152, §1(4),and we have no insurance required.]t employees. 12.0 Roof repairs comp. insurance required.] 13.[]Other `Any ePPlicsnt that checks boa'#I muz also fill out the section below showing their workers'etimpansetion poi icy in t Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. 4contraown;that cheok this box mustatteehed an additional shwtshowing.the name of the sub,eonttactots and their workers'comp.policy information. 1 am an employer that.is providTff:workers'compensation insurance or a to ees Below is. information. f �' y the policy and job site Insurance Company Name:_ r-------------------- a Policy#or Self-ins.Lie.#:_ ( � �C �'d r—ly Expiration Date:__4V2JCV0 Job Site Address:__ � � City/SwzrLip: rf h ,106vel-�( 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 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 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 Si titre: Date: Phone 4: s? Ofltcial 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): I. Board of Health 2 Sailding Department 3.City/Town Clerk 4. Electrical Inspector 5. PlumbEInsper-tor 6.Other Contact Person: Phone#: ♦?yy' 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'.iicense number on the appropriate line. City or-Town Officiah; Please be sure that the affidavit is complete and printed legibly. The Department hes 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 fuf=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 parson is NOT required to complete this affidavit The Office of Investiptions 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 42111 Tel.9 617-7274900 Ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-774 www.mass.gov/dia