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HomeMy WebLinkAboutMiscellaneous - 540 BOXFORD STREET 4/30/2018 (2) �5H BUILDING FILE ��1NOFn�gss 2� MICHAEL 9C' 0 J. N SERGI m U No.33191 100'BUFFER ROFE S' P4 0 RV , \ a N EXISTING LOT 'l FOUNDATION TOF EL.=131.6 / 6 a o � s iso 100' BUFFER �� • ov: � I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO THE HORIZONTAL SETBACK REQUIREMENTS OF THE LOCAL APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED. (THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER LLC RESTMCAONSSUCHASGOVENANTS,WETLANDS,EASEMENTS, CLIENT: S & L HOMES ORDERS OF CONDITIONS,ETC.)THIS DRAWING SHALL NOT BE USED THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT BY THE GUENT FOR ANY PURPOSE OTHER THAN THAT OUTLINED ABOVE,EXCEPT WITH THE WRITTEN PERMISSION OF CHRISTIANSEN LOCATION: NORTH ANDOVER,MA. &SERGI INC.FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OF CHRISTIANSEN&SERGI INC.AND ANY DATE: 8125/15 SCALE: 1"=80' UM4VTH0MZED USE 1S PROH)91TED.CHRISTIANSEN&SERGI TAKES NO RESPONSIBILITY FOR THE UNAUTHORIZED USE OF THIS DRAWING ORANY INFORMATION CONTAINED HEREON. PROFESSIONAL ENGINEERS & LAND SURVEYORS CHRISTIANSEN & SERGI, INC. 160 SUMMER STREET, HAVERHILL, MASSACHUSETTS 01830 WWW.CSI-ENGR.COM TEL.978-373-0310 FAX. 978-372-3960 DWG.N 0.:14036.001.017 � l � NoRTy q O SLED bt k 0 i ; �0 APPLICATION FOR CERTIFICATE OF OCCUPANCYIINSPECTION "Argo P, �� BUILLDING PERMIT# 1®8 1 9SSAC14us ADDRESS/LOCATION OF PROPERTY: �-Lj® Map 1 OS- C Parcel Lot Number �c SUBDIVISION:__�i I/ DATE REQUESTED FILED/READY FOR INSPECTION: CLOSING DATE ON PROPERTY: FIVE 5 DAYS NOTICE PRIOR TO CLOSING DATE IS REO UIRED ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20.00)WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. APPLICANT SIGNAT Permit Issued to: L riom c � Address: b ��� \ ,(�E �V :� �W A-btj (A �)N,�+0 ROUTING TOWN ENGINEER, SITE PLAN—DRIVE-WAY REVIEW ' ' �llq itv 9% CONSERVATION PLANNING ❑ �J �-G�M ' aJ29'?�i(o DPW-WATER METER M ❑ � �l/� �22 (P SEWER CONNECTION,�/ . ❑ �/ �J�% 2 16 DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCYANSPECTION REQUEST / •rY�ji I..„ DPW �� !(�' T,6p_ �r y SIGNAi'URE C. j r File:Application for OC form revised Jan 20 /2011, � d " + ?i •,�•'CHUS 49 CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 908-15 Date: 04/19/2016 THIS CERTIFIES THAT THE BUILDING LOCATED ON MAY BE OCCUPIED AS Single Family Dwelling IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: S&L Homes LLC. 540 Boxford Street North Andover,MA.01845 Building Inspector i � poerN q Q �TLEO !6 APPLICATION FOR CERTIFICATE OF OCCUPANCYANSPECTION 'Z oyy AoRATEO spa'�5 BUILDING PERMIT# ADDRESS/LOCATION OF PROPERTY: 60v('.wk Map j Or- C_ Parcel Lot Number SUBDIVISION:_ II DATE REQUESTED FILED/READY FOR INSPECTION: CLOSING DATE ON PROPERTY: FIVE(5)DAYS NOTICE PRIOR.TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20.00)WILL BE CHARGED IF THE-STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. APPLICANT SIGNAT Permit Issued to: Address: 10 -E' -- ROUTING TOWN ENGINEER, SITE PL N—D E-WAY REVIEW; ' y� ��,q CONSERVATION PLANNING ❑ N�'� ` M (� 3)29 f 1�l(� DPW-WATER METER Xl1,q -7�11&/ SEWER CONNECTION /,- ❑ � ��G,/ _ ZZ 16 DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW 'v �T9_ - ��'1� -2Z-�� G _ , ,, , y ' , C NAS URE C. y `i P4� File:Application for OC form revised Jan 207/2011,` �Ta 5 s' ti ' �ll 6 1 3• kl f gi'.'fi �! � NORTH Town z 1E ndover No. 6 h y h ver, Mass, 12 2-01 1 o CO[NIG -C . 1 0 V BOARD OF HEALTH Food/Kitchen PER MIT I D Septic System THIS CERTIFIES THAT ..............�?.. ...Lj........... ... BUILDING INSPECTOR s.............. ........................ ............ ..... LLC atio � has permission to erect .......................... buildings o .... ... . .,1- ., l � Rough to be occupied as ........... ©� 44 �l p� .. .. ....... .. ��..... ....... ....................................................... Chimney provided that the person acoeptin his r it shall in e. e.ry respect conform to the terms of the application final C�h on file in this office, and to the provisions of the Codes and By-Laws relating to the inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTQB XT Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. p Final Y7- / PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TARTS Rou Service �� ........... ..... .............................. Final '`�✓L_ f/ BUILDING INSPECTOR 2 -44 - GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough j y Display in a Conspicuous Place on the Premises— Do Not Remove Final 46S q_7_`6 445�� 314- No Lathing: or Dry:.Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Buil-ding Inspector. Burner 7. - Street No. ' � Smoke Det �/ - Date..... ............ f Rrf,A .", . '..tio TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING sSACHU This certifies that .........................`.,7. .......................................................................................... ............ has permission to perform ...................11............. wiringin the building of............. '**'*........................................................I....... ..................... at ..5-�/o..... ............North Andover,Mass. ..................... Fee....Y Lic.No. J.. . . .................................................... L�V 7Y.7 ELECTRICAL INSPECTOR Check# 12.6 7 8 Commonwealth of Massachusetts Official Use Only Department of Fire Services permit No. Occupancy and Fee Checked ,w s 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(MVoW_i_r>e_s."_(PLEASE PRINT ININK OR TYPE ALLINFORMATION) Date:City or Town of: NORTH ANDOVER To the Ins; c By this application the undersigned gives otice 's or her intention perfo the electrical work described below. Location(Street&Number) Owner or Tenant Telephone No. ' Owner's Address Is this permit in conjunction w4ftha building per 't? Yes W No ❑ (Chec Appropriate Box) Purpose of Building Utility Authorization No. tl A - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service 2—Vd— Amps 1 olts verhead❑ Undgrd r4je-"�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 LuminairesNo.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires 1 Swimming Pool Above ❑ In- ❑ o.o mergency Lighting rnd. rnd. Batter Units No.of Receptacle Outlets l No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices Total � No.of Ranges No.of Air Cond. Tons No.of Alerting Devices Heat Pum Number Tons KW No.of Self-Contained No.of Waste Disposers Totals - Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection No.of Dryers 1 Heating Appliances KW Security SystDeviems:* or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent r7 ecommunicallo.Hydromassage Bathtubs No.of Motors Total M? TelNo.of Devicesoor E ns u vWirinalent OTHER: ®ve Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of E �GE: ti1 G d (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE nless 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 covers is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: 1NSURA=NCE BOND ❑ OTBER ❑ (Specify:) I cert,under th p i s and p alt' s per' ry,that tli "tformation on this application is true and complete. FIRM NAME: G• LIC.NO.: Licensee: Signature LIC.NO.: (If applicable, r "ex t"int a h ens a er 1' e.) Bus.Tel. Address: v Alt.Tel *Per M.G.L c. 147,s757-61,security work requires DEpartment of Public Safety"S"Lic nse: Lic. o. OWNER'S INSURANCE WAIVER: I am aware hat 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 r.PERMITFEE. 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 r 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.bc 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: R Trench Ins etion p Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: i —I z -I ,' SERVICE ECTION: Pass Failed❑' Re-Inspection Required($.)❑ Inspectors Comments: . Inspectors Signature: Date: // 6 lr PARTIAL ROUGH INSPECTION: Pass F Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: r Inspectors Signature: Date: ✓ ROUGH INSP TION: Pass M V Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: u,,�, __� Date: FINAL INSPEC ION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: �_, Date: Z —lo DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of MassachusettS 10 Department of IndustfialAccidents • - . `_ 1 Congress Street,Suite 100 Boston,MA 02X14 2017 q�r www.mass.gov/din aM s��v workers Compensation Insurance Affidavit:Builders/Contxactors/Eleetricians/�'lum ers. TO BE FILED WITH THE PEW&TTING AUTHOR q Y. Elease Tint Legibly A lica at Information' G p r Name(Business/OrganizationlIndividual): Address: �� ` Phone#: 7(>�J✓/.��rl 7 City/State/Zip Are you an employer?Check the appro late box: Type of ct(required); em to ees frill and/or part-time). 7. evW gOristriiation 1. I a a employer with P y 2 am a sole proprietor or partnership and have no employees working fox me in $, Remo deliiig Vcapacity.jNoworkers'comp.insurance required.] 9, Demolition 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10[]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no'eniployees. 12.r [Pt,—fmD ng repairs or additions 5-❑I am a general conisacto f and I have hired the sub-contractors listed on the attached sheet. 13•.[]Ro6f repairs These sub-contractors have employees and have workers'comp.insurance.t 14.Q Other 6.❑We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),andive h insurance required.] !6 no empldyees-[No workers'comp. n policy IAny applicant that ch$gks�s#& I sdi�out eysection are doing all work andthen hire ow S�Oing their utside contractors ors m st submit as ew affidavit indicating such I Homeowners who subuut tcontractors that check ibis box must attached an 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. and job site viding lwrkevs'compensation insurance for my employees. Below is the policy I am an employer flint is pro information. Insurance Company Name: ExpirataonDate:. L� Policy#or Self-ins.Lic. //Z;�/ - City/State/Zip: lob Site Address: Attach a copy of the workers'comp, ion po&cy declaration page(showing the policy number and expiration date). al violation b up to 0-00 Failure to secure coverage as required nderMGL enalties2inthe form of m25A is a � punishable STOP WORKORDERand afie of up to$250.00 a and/or one-year imprisonment,as well 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. I do hereby cert' er the s dpenalties ofpeijury t/rat the information provided above iand correct. ai Date: Si ature: Official . Do notwrite in this area,to be completed by city or town official. ofdt- zine only. Permit/License City or Town' # Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing inspector 6.Other phone#: Contact Person: C0MM. � °pNop o F S,igu IS Rf ES rHf �� R d t7 SEAS QST LLO SANS 'BAR p EL £}� MASr fR � GARY EcTRlc EC7'Rl.. 100 pH WARD Cp INS' . AaN� EfR 4_P 0 sx 88 r 8E48 A '. N , 038 rr``r , �` e f� 7 J-111:6 5, 088 J .@COMMONWEALTH OF MAS -CHUSETT:S � o o • o o BOARD`OF EtE£TRICIANS;: ISSUES TWE FOLLOWING` LfCENSE ASA RSG JOURNEYMAN 'ELECT IC ANS ; 1 ! H i G-ARY'<H WARD P 0 BOX loo DE1 R DRIVE S�. VER LAKE 'NH 03875 5403 j 17427 07/31116 74048 \ Date....ql!:-/.. X1256 of,40RT TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that............/< !., ......... A P.5...�t..................................... has permission to perform...........).......................... ...................................... plumbing in the buildings of.....S../...1-4................................... at........52- ......52-1 ........ 4........................................ North Andover, Mass. Fee?/.7p. Lic. No. &95� ...........*..................................................................... PLUMBING INSPECTOR Check# + MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK + CITY /'d. n UYP/" MA DATE - i I 'f PERMIT# JOBSITE ADDRESS 5��� a OWNER'S NAME POWNERADDRESS _ _ _ TEL _ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:P RENOVATION:® REPLACEMENT:® PLANS SUBMITTED; YES© NOE] FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 118 9 10 11 1 12 1 13 14 BATHTUB I — � — ! CROSS CONNECTION DEVICE I DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM _ DEDICATED GREASE SYSTEM ` DEDICATED GRAY.WATER SYSTEM v DEDICATED WATER RECYCLE SYSTEM I _ I I DISHWASHER DRINKING FOUNTAIN _ FOOD DISPOSER FLOOR I AREA DRAIN — INTERCEPTOR INTERIOR KITCHEN SINK _ i I _ LAVATORY ROOF DRAIN r --- SHOWER STALL I _— SERVICE 1 MOP SINK TOILET URINAL I _ _j I WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _ WATER PIPING _ ' OTHER — INSURANCE COVERAGE: I have a current liability 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 THEAPPROPRIATE BOX BELOW ! LIABILITY INSURANCE POLICY 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 I 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 in compliance with 11 p ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. //J PLUMBER'S NAME LICENSE#P11-,'ZSIGNA MP® JP® CORPORATION Q#PARTNERSHIP®# LLC®I# COMPANY NAME du/ Y nl 7 i hC.. ADDRESS G X CITY 44 1& STATE ZIP Df TEL 'O FAX CELL EMAIL (i-eti 0 0� � •�. ��� -� �"� ��, �� �� - _ �i Date... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ,ssACHU This certifies that ....... has pernlission for gas inst Ration S, 44. ... . ............................ ................... in the NL111daings of * - 01--OA .. 4;��at............................. ......................... .. North Andover,Mass. Fee... Lic. No. ..X025....... ..................................................................... A GASINSPECTOR Check#. eZ /Ju- V-n n f i �I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK a s '- CITY �� �'p��+✓' MA DATE�I� ��� PERMIT# JOBSITE ADDRESS Y'S I J YJ"Gr[Y �>� OWNER'S NAME sw /yam s" OWNER ADDRESS N ., r TEL _ TAX: TYPE OR OCCUPANCY TYPE COMMERCIAL i � EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:'/ RENOVATION REPLACEMENT:_-_3 PLANS SUBMITTED: YES _ NO APPLIANCES 1 FLOORS-- BSM 1 2 3 45 6 7 8 9 10 11 12 13 14 BOILER F BOOSTER CONVERSION BURNER ____ _a i COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE .,..;_. ..... ._..__.. ,,,._ : „ _..,,... .. . _. ,... ; ..... _.l FRYOLATOR .w.�_ _.J _ = _ _l FURNACE I GENERATOR Jl .... ... GRILLE INFRARED HEATER _._..l LABORATORY COCKS i t MAKEUP AIR UNIT _I f OVEN _..... ne��. t.. .. _ . __,. ?...... .. POOL HEATER i ROOM I SPACE HEATER _..._ . ROOF TOP UNIT s TEST .._.. .. UNIT HEATER 1 UNVENTED ROOM HEATER MATER HEATER _ ..,.._. , f OTHER _._.._ . I3 I ( , INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1f NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY V�f OTHER TYPE INDEMNITY �,,, BOND I'.... 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 ..,_.i SIGNATURE OF OWNER OR AGENT 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 in compliance ith all P anenttppf ovisi n of the Massachusetts State Plumbing CodeandChapter 142 of the General Laws. .41 � PLUMBER-GASFITTER NAME /�f"✓� l��//�'�/"� LICENSE SIGNATURE"" MP ✓ MGF JP _ 1 JGF LPGI,_j CORPORATION,�z# / G x PARTNERSHIP # LLC # COMPANY NAME �tt����`'� 2r ✓OrS /'02(/-'Y.L�ADDRESS _..�,.�ed;2 3S_ � CITY /!/u?ZTin9 �1 ,,,.�.. .. _.....,..,,. a STATE A, ZIP O3� TEL( FAX M, CEZI274V ;'EMAIL �J!'�X+,� �`t� /V�e✓�+'.r� )53ee) Cel,- Od1 � 4 I 3 T'he Commonwealth of Massachusetts Department oflndustrialAccidents R - •r 1 Congress Street,Suite 100 = Boston,MA.02114-2017 k, ;� . :�,�� www mass.gov/dia Workers,Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers- TO BE FILED WITH THE PERNUTTMrG AUTHORITY. Applicant Information l/ Please Print Lealb Name(Businessiorganization/individual): % d Lt/ �. t' ��d►�r Addxess: �eX v? 3, City/State/Zip:�/v j,� 414,kle X''Q Phone#• 5p7,v -` aJG Are you an employer?Check the appropriate box: Type of project(required): 1. ', 1 am a employer with _employees(full and/or part thee).* 7. �New construction 2.Q 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. El Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my properly. I will ensure that all contractors either have workers'compensation insurance or are sole 11.1]Electrical repairs or additions proprietors with no employees. 12..0 Plumbing 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.inswmce.$ 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[]Other 152,§1(4),and we have-employees.[No workers'comp,insurance required.] "Any applicant that checks boxB1 must also fill out the section below showingtheirworkers'compensationpolicy information. Ti Homeowners who suhmif this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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-c6n6c6s have employees,they must provide their workeis'comp.policy number. I am an employer that is p' viding workers'compensation insurance for my employees.'Below is thepolicy and job site information. Insurance Company Name: ✓'/� 7' �t'�C I(° '9 ? 1 Policy#or Self-ins.Lic.#: ale J/�49 Expiration Date: � �o; /�dX�//+' ;-z' Ci /State/Zi (J2 /,a r P'a l • Job Site Address: ' t3' p��'/' Attach a copy of the workers'compepsation 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 the pains and enalties of perjury that the information providY�l ve is true and correct Date: / Signature: Phone# / y / 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#: 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 611&, 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 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 ­ reqiiredto 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.4 617-727-4900 ext.7406 or 1-877-MASSAFE Fax 4 617-727-7749 Revised 02-23-15 www.mass.gov/dia V i ` .. ... ._ sem..,.i.. •[s-7'"��_"��'--� 1 (o,.::COMMONWEALTH OF MASSACHUSETTS o. . o ' Q OARD�p +PLUMBERS AND ,ASF ITT:ERSn=.' + :FO'LLOW(NG,IICEit!IS E j ++ L I CEN`S£D AS A MASTER. PLu BE!R irf I mss, ", KENWETH J POWDERLy iwt: 44R�OND LN ri (o t L B0X- 2'35 latl�r tfTT1.fG «LAKE MA Q1865 ' 41AOj25 p` , p'j%16: 214741 { a Jtlploq 94l U Date... .. . q .......... OF NOiiTM,� TOWN OF NORTH ANDOVER PERMIT FOR WIRING CH This certifies that ... ........................................................................................... has permission to perform .......:. .. �. . . .. ......... ..I....................... L �k C.. wiring m the buil ng of............................................. ^- - `...................................... 9. k at ....":�...C..-...... ....................... . . . �.......................: ... ... .........,North d ver,Mass. Fee.. - .L ....Lic.No.�Xd-r ...... ... ELECTRICAL INSPECTOR Check# Use,Only � Commonwealth of Massachusetts fficial Us Affj Department of Fire Services Permit No. Occupancy and Fee Checked a BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (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 INMK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the 1 s ecto of T'ices: By this application the undersigned gives notice ofhis or her' tent. to erform the electrical work described below. Location(Street&Number) r^ Owner or Tenant Telephone No. Owner's Address Is this permit in conj u with a bui ing permit? Yes No (Check Ap ro riat Box) Purpose of Building ���- Utility Authorization No. Existing Service 470— Amps olts Overhead❑ Undgrd❑ No.of Meters New Service Amps I Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: a Completion of the following table may be waived by the Inspector of Wires. ' Trans No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Total Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ No—.—of 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. Tonal No.of Alerting Devices No.of Waste Disosers Heat Pumpum Nber Tons KW No.of Self-Contained p Totals: ............................................... Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection � No.of Dryers Dr Heating Appliances KW Security Systems:* f 3' No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: j Heaters KW Signs Ballasts No.of Devices or Equivalent Wirin1 No.Hydromassage Bathtubs No.of Motors Total HP TelNo.of Devicesons 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: 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,tender th pa' s and p of ury,tli t the information on this application is true and complete. / FIRM NAME: r LIC.NO.: (O Licensee: Signature LTC.NO.• (If applicable,wer"ex t"to the lie n ber e.) Bus.Tel.No.: Address: Alt.Tel.No.: *Per M.G.L c. 147,s. 7-61,security work requires Apartment of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am awar 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. ❑ 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 i electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the Y notification of completion of the work as required in M.G.L.c.143,§3L. Permits shallbelimited 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 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: f�� Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: a ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass F?] Failed Re-.Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com r .The Commonwealth of Massachusetts F Department of 1•ndustrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 •; �F www.muss.gov/dia RM1 5J'Vv workers,Compensation Insurance Affidavit:Builders/Contractors/Electricians/I'lumbers. TO BE k'LLED WLTH THE PERMCTT lNG AUTHORYy' Please Print Le. 'bl A licaut Information Name(Business/Oiganization/Individual): Address: �U n, /,+� City/State/Zip a Phone#: �'/ 7 Are you an employer?Check the appro !ate box: Type of J ct(xequired): em loyeas full and/orparttime).' 7. ew'constriiction 1. I a a employer with P y 2 am a sole proprietor or partnership and have no employees working for me in S. []Remodelingany capacity. NO workers'comp.insurance required-] 9. ❑Demolition 3.E]I am a homeowner doing all work myself[No workers'comp.insurance required]t 10E]Building addition 4-❑I am a homeowner and will be,hiring contractors to conduct all work on my property. I will 11.❑Electrical xepairs or additions ensure that all contractors either have workers'compensation insurance or are sole I proprietors with no employees. IZ Plumbing 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.t 14. Other 6.C]We are a corporation and its.officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no empldyees:[No workers'comp.insurance required] Any applicant that cheoks boXtil must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit•thus 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 statg 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 that is providing workerscompensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Expiration Date: Policy#or Self-ins.Lic.#:. 000�l C�l City/State/Zip: Job Site Address: Attach a copy of the workers'coanpepshtion 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 foie up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORD 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. 71doherebycert' er the ai sdpenalties of per jury that tite informationprovided above is true and correctDate: Of use only. Do not write in this area,to he completed by city of town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.other Contact Person: Phone#• f 1, V Information and Instructions Massachusetts General Laws chapter 152 requires allemployers to provide workers'compensation for theiremployees. 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 enferprise,and including the legal representatives of a deceased employer,or the receiver•or trustdd 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=h-as 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 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. 13e advised that this affidavit maybe 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 IndustrialAccidents. 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 thai 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 wwwmass.gov/dia i OMIVIONWEALTH OF M 'SSACHUSETS ELECTRICIANS ISSUES THF.. :FOLLOW ING L-I CENSE ( `� REGISTERE:p MASTER E;LECTR`l.1,1 .{ LECTR I C CO INC I;AFY H WAF�D t 100 DEER 6 o, Box 88 �� •�� �` SL.C'yER LAKE NH 03875-00 � 8$ f� , 8648 A 07/91/.1b 74047