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HomeMy WebLinkAboutMiscellaneous - 554 Turnpike Street (5) ��� ����,�c �- � C��l�`—'� �/ i ----� d Date.. ................. ..... kORTH 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING S 14US . .... This certifies that ...... .......... .............e ................... has permission to perform wiring in the building of ........ ............................................ at.... ....../:........ ..........I..... North Andover—,Mass. Fee'14J'—.Or........ Lic. ................... ........EEM CAL INSPECTOR - �i�� � i/ Check # Official Use Only Commonwealth of Massachusetts Department of Fire Services Permit No. 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: 5f-oZ y-d 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) 6-,rS Tanmolr-i - L tiarwut, 4YWCAJ Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit?4 13 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: _ EeC /d rcEA 3 1:)4v3Lr- n voc.L A f- rwv v e Completion of thefollou4ng 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 nd. rnd. Batte 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 Tons No.of Alerting Devices No.of Waste Disposers Heat Pum Number Tons KW No.of Self-Contained TotalsDetection/Alerung Devices Municipal No.of Dishwashers Space/Area Heating KW Local❑ Connection El Other No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Watero.of No.of Heaters- KW Signs Ballasts. Data Wiring: No.of Devices or E uivalent No.Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsWiring: No.of Devices or Equivalent OTHER: A Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: .Sc-'4•urO (When required by municipal policy.) Work to Start: d.S--oFs 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 Y] BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: MV/VL/^ edAya LIC.NO.: 7 Licensee: M JWz, ,,;v&- Signature --5� - LIC.NO.: 1a 9 (If applicable, enter"exempt"in the license number line) Bus.TeL No.: Z o 3 tj/9 yea 93 Address: 4� P-IT-r&-n/ /-,p m FAA-i,t„WA- ,11) 6305'y Alt.Tel.No.: *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 J required by law. By my signature below;I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent Owner/Agent PERMIT j Signature Telephone No. FEE:$ � I I L .\.?a.,' i,_\' �v� `� �� �. q ��. -��.-.- `► The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations �a 600 Washington Street Boston, MA 02111 {j www.mzass gov/dia . Workers' Compensation imitranee Affidavit$udders/Contractors/Electricians/Plumbers Applicant Information Please Print LeQibty Name(Business/Organizadon/Individual); Address:City/State/Zip-phone #: . Are you an employer?Check the appropriate box: I.❑ I am a employer with 4. ❑ I am a general contractor and I Type of prelim(required): employees(full and/or part-time).* have hired the sub-contractors 6• ❑New construction 2.❑ I am asole proprietorr or partner- listed on the attached sheet.# 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. Q Demolition` working for me.in any capacity, workers' comp.insurance. q. M Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10-❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 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. in.surancerequired.] 13.[]-Other "Any applicant that checks bo)e#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheet showing the name of the sub+cmttrwt=and their worker:'comp,policy information. 1 am an employer that.is providing workers'compensation insurance for nW employees: Below is.the information policy and job site u Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: J Job Site Address: City/StateMp: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration d04 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 certify under the pains and penalties of perjury.that the information provided above is true and correct Sinttature: Date' Phone#: E only. Do not write in this area,to he completed by city or town official n• Permit/Lieensehority(circle one):Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector son: Phone#- r: Information and Instructions 1r 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 ofthe'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 perfornivice 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 certificate(s)of I nsurance. 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 pem' it or license is being requested,notthe 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 sC. 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 indicstting•current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or r<� town)."A copy o fthe 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 � L Tel.# 617-7274900 ext 406 or 1-877-MASSAFE Fax#617-727-7744 Revised 5-26-QS www.mass.gov/dia Location No. 1,,13 G Date ` "a NOR,h TOWN OF NORTH ANDOVER Of Tito , ow a � a Certificate of Occupancy $ . o i s,KMUstt�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ /` • Check # 74� j 72 —Building Inspe�or M �h. • CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 613 Date: May 22,,2008 THIS CERTIFIES THAT THE BUILDING LOCATED ON 555 Turnpike Street—Chestnut Green#41 MAY BE OCCUPIED AS tenant fit un— doctor's office v IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Stephen Galizio.MD 555 Turnpike St North Andover MA 01845 Building Inspector 4 own- o ° over 0 No. 3 SOL 0 LAKE o dover, Mass., �� d COCMICKEWICK �d ADRATED S BOARD OF HEALTH Food/Kitchen .PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT......Da..........� . ... ..... Foundation has permission to erec ...............................:........ buildings on .. P..... t!f'........... . Rough to be occupied as... ��"� .... 0 � .......4A!...�..�................. ............................................ Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application 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 INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTR C Tai Rough f" ......... .... ............................................................................ .. Service BUILDING INSPEC incl C]6L. ✓-�-�!�- ��� Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner - b Street No. SEE REVERSE SIDE Smoke Det.