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HomeMy WebLinkAboutMiscellaneous - 565 OSGOOD STREET 4/30/2018 565 OSGOOD STREET 565 OSGOOD STREET 210/036.0-0017-0000.0 210/00000.0 i I I i 7341 Date... ..Z—.6. HORTFI °f TOWN OF NORTH ANDOVER PERMIT FOR GAS_INSTALLATION s . SACHUSES This certifies that �� L�f�fY. . .. . . !�`� ��. . . . . I' has permission for gassiinstallation(::�,4,7 IFt w,i0G64-7 . . . . . . . . in the buildings o /' �L.y . '<',�� . ./.:l� St'�✓4 ?�. . at � " . . s 5�' . . . . . . .. North Andover, Mass. Fee Lic. No. . . . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR Check# i MASSACHUSETTS UNIFORM APPLICATION FOR,PERMIT TO DO GAS FITTING City/Town: N r /t���yL� , MA. Date: ' l v Permit# Building Location:'7 (D, —_ o: con ST Owners Name:b Az y co/o/0 Type of Occupancy: Commercial Educational❑ industrial"❑ institutional❑ Residential❑' New: Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No ❑ FIXTURES W UJ vi Z H to V x z 0 W W � O w u . w,, m a � , ,; . 6 x (n V z W Lu ZW O W. 0. F- x W W w z ga rn x W I' z w a a Z W N J ~ ~ m W O z O ~ t— W F W v o o u_ O O x x _ o a lX W t- > > > 3 O SUB BSMT. BASEMENT —1—FLOOR 2NO FLOOR 3 FLOOR __4'FLOOR 5 FLOOR v ,6 FLOOR. —f—FLOOR 8 FLOOR Check;One Only Certificate# Installing Company Name: cltu'A I bU2 kc- fCa- ! ����^^,, -rte Corporation 7 Address 91 I L (J01L)r Sl City/Town � State:. ❑Partnership Business Tel: Fax: ❑Firm/Company Name of Licensed Plumber/Gas Fitter: (; INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 Yes[No❑ If you have checked Yes.please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:1 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 Owner's Agent By°checkmWthis box Elf hereby certify that all of the details and information f have submitted for 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 all Pertinent provision of the Massachusetts State Plumbing Cod and Chapter 142 of the General Laws. AA Type of License: By B Plumber Title ❑Gas Fitter Signa Licensed Plumber/Gas Fitter EJ-Master Citylrown ❑Journeyman License Number. ^ APPROVED OFFICE USE ONLY ❑LP Installer y. Date.... 4,, TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING C IH4 U This certifies that ..... ........................ has permission to perform .... ..........(........................... wiring in the building of ...... .......... at....... ..................................... .North Andover,Mass. Fee.. .................. . .. .......... Li Check # 89.64 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. 1/071 (leavebiank APPLICATION FOR PERMIT TO PERFORM ELECT All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 WORK (PLEASE PRINT ININKORTYPE ALL INFORRATION) Date: City or Town of: NORTH ANDOVER �—�—' By this application the undersigned gives notice of is or er intention to perform the el�electrical described below. Location(Street mber) Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes El No Purpose of Building LVJ (Check Appropriate Box) Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd© No. of Meters i New Service a0b _Ikqb Overhead Undgrd No.of Meters ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1 . Com letion o the ollowin table m be waived b the Ins ector o Wires. No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans No.of Total . No.of Luminaire Outlets Transformers KVA No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In_ o.o mergency ig g d. rnd. Batte Units —. No.of Receptacle Outlets No.of Oil Burners FIRE.ALARMS No.of Innes No.of Switches No.of Gas Burners No..of Detection and No.of No.of Air Cond. Total Ranges Initiating Devices Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: �"---....._......_. _.._._._.... _. Deteetion/Alerting Devices No.of Dishwashers Space/Area Heating:KW Local❑ Municipal No.of Dryers Heating AppliancesConnection El Other , Security Systems: No.of Water No.of Devices or E uivalent Heaters KW No.of o.of Signs Ballasts . Data Wiring: No.of Devices or E uiv No.H alent Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent °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 Stark 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 cov ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCEVj BOND ❑ OTHER I certify,under t pains and penalties o [3 (Specify:) f perjury, that the information on this application is true and complete. FIRM NAME: l ,Q- Licensee: �V lb :y�. � LIC.NO.: o Signature (If applicabl, en empt"i e license nu ber line.f LIC.NO.: Address: —4 y -� Bus.TeL No.: I�� 03��� *Per M.G.L c 147,,s. 57-6 1,security work requires D Alt.Tel.No.: OWNER'S INSURANCE WAIVER: Ian,aware that Department doles noSaft have the liability .No. nce normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner coverage ❑ owner'agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ - ". . � '�� �.. �,� �� �� � �� �� D� �'CJ lj �"�/. 1 �� i J' i The Commonwealth of Massachusetts k1 !! Department of Industrial Accidents ! Office of Investigations 600 ffashington Street Via .�, Boston, MA 02111 www.nzassgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibl Name (Business/organization/individual): t. Address: City/State/Zip:_ Phone #: 33� Are you an employer?Check.the appropriate box: I.['►�I am a employer with 4. ❑ I am a general contractor and IFoject(required): employees(full and/or part-time).* have hired the sub-contractors New construction 2.❑ I am a:sole proprietor or partner- listed on the attached sheet,r odeling ship and have no employees These sub-contractors have olition working forme.in any capacity, workers' comp.insurance.[No workers com . insurance 5. ing addition req ' p ❑ We are a corporation and its cored officers have exercised their trical repairs or additions 3.❑ 1 am a homeowner,doing all work right of exemption per MGL bing repairs or additions ` myself.[No-workers,comp, C. t.52, §1(4),'and-we have no insurance required.) 12.❑Roof repairs 9 ], .employees.[No workers' comp. insurance required.] 13.❑Other `Any applicant that checks borC*1.must also-Mout the section below showing their workers'oompensatiori policy information t Homeowners who submit this afidavit indicating they ars doing all work and then hire outside contractors must submit a new affidavit indicating each. $Contractors that check this box nivatattached an additional sheet showing. B ng the name df the sub-com actors and their workers'comp.lPoli'infom�atio aa. m an employer that is providing:workers'compensation insurance for my employees; inforBelow is the policy and job site mation. Insurance Company Name: ' Policy#or Self-ins.Lie.#: ^1 Expiration Date: ------------- Job Site Address. City/State/Zip: D6 �tj1� �6' Attach a copy of the workers' compensationpolicy declaration page(showing the policy number and expiration date Failure to secure coverag 500 e as required,under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1, ,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 Offi Investigations of the DIA,for insurance coverage verification, ce of Ido here ify under the ins and enaitia o er P /P %&Y tiiat the information provided above is true and correct Si tore: Date: Phone#: l0 3 ficial use only, Do not write in this area,to be completed by city or town official City or Towa: Permit/License# Fssuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing robing lnspector Contact Person: Phone#• Information a:nd .Instructions T1 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 t mstee 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. L chapter 152 25C 7 states"Neither the commonwealth nor an of its.political subdivisions shall Additional , MG ,§ ( ) Y �' 1�' 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 toyour situation and,if necessary, supply sub-contactor(s)name(s),address(es)acid 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 cavy 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 io of insurance coverage.. Also.be sure to s' and date the affidavit. The affidavit should t confirmatr n Accidents for � � be returned to the city or town that the application for the permit 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 numberlisted below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete acid 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 permittlicense number which will be used as a reference number: In addition,an applicant that must submit multiple permittlicense 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 ofthe 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. ✓ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel.# 617-727-4900 ' t 406 or 1-8.77-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia 04t (fammunwalA of Auzzat4widto Office U ]/Only (X�� DePwinum of Public Sq ety Permit N . BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy & foe Checked 3M (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusens Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) t. City or Town of_ ,2` ��U To the Inspector of Wimp The undersigned applies for a permit to perform the electrical work described below. ! Location (Street d Number) -�4 A 6,5 6-oo-0 $,�, G-.1 \hf✓�n5 / �-nS\S c v�, Owner or Tenant A 15 It ii t4 L 1754/U C`�l a vl, i� F24 4 07 U Y P h h 1 Owner's Address eOq NO, 47&Jtr Is this permit in conjunction with a building permit: Yes No (Check Appropriate hotel Purpose of Building l p" //1+1 Utility Authorization No. l2 Q 12 13 2. Existing Service Amp / :+ol;s __ Overhead:❑Ond�rd n❑ _ No.of Met= New Service -2—o-01-Amps 12c, 2 `fy Volts Overhead 11Undgrd LJ— No.of Mews Number of Feeders and Ampacity 2 SG J✓�C, X)4- { Location and Nature of Proposed Electrical Work G`-C lei' !l�11i! J .tet. !cc:, TOTAL No. of Lighting Outlets No.of Hot Tubs No. of Transformers KVA -Above In- No. of Lightind fixtures Swimming Pool grnd. ❑ itmd. ❑ Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners 'Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No.of Zones...�. Total No. of Detection and No. of Ranges No, of Air Conditioners Tons Initiating Devices -Hea= TolarTotal No.of Sounding Devices. No. of DisPosals No. of Pumps Tons KW No.of Self Contained DeteauANSoundin Devices S ce/Area heating g ' No. of Dishwashers KW Municipal �— LocalD Connection ❑Other No.of Dryers Heatin Devices KW No.of No. Low Voltage No. of Water Heaters KW Signs Ballasts I Wifirill No. Hydro Massae Tubs No.of Motors Total HP OTHER: INSURANCE COVERAGE: Puts t to the requirements of Masmhusties General Laws I have a current Liability Ins a Policy including Completed Operations Coverage wits substantial equivalent.YES O O 1 have submitted valid prod of same 10 this office.YES NO U If you have checked YES, please indican the type of coverage by checking the approprim bou. INSURANCE U BOND ❑ OTHER❑ (Please Specify) 11/ti 6 (Expiration DaW Estimated Value of Electrical Work f Work to Stan Inspection Date Requested: Rough Will 'call Final Will ca11 Signed under thepenalti of perjury: EWING ELECTRIC COMPANY 13173A FIRM NAME LIC. NO. Licensee Barry F. Ewing Signature "'. ��'--- - ---- LIC. NO.2 9 7 6 2 E Address 475 North Street, Tewksbury, MA. 1876-1299 ( 508 )851-7693 Bus. Tel. No. Alt. Tel. No.( 508 )622-2472 { OWNER'S INSURANCE WAIVER:I am aware that the Licensee does not have the insurance coverage or its substantial equivalent As required by MassahchiaM General Laws,and that my signature on this permit application waives this requirement.Owner Agent (Please check one) Telephone No PERMIT FEE i 2 (Signature of Owner or Ago* Date....m,�. ...1�6: t,�NORTFI:,4. TOWN OF NORTH ANDOVER U Y PERMIT FOR WIRING t Ulm US t �` rfcl2�L �v ' � This`certifies that ..:. ,--..` ... ........ ....... ..... ............................. has permission to perform ............ :. ........kN tea.{ .`.". \A wiring in the building of `J ` .. .....\.v 0 '� C t1� at .:::� .#�o ..1a.:5.G--�6. ..... ...... .. ..,. ,North Ando er,. • / /Lie.No..f.. �.7.J�:.:.:.. .. :... !L :......, ..? ..... .. ELECTRICALINSPECTOR pIr j � 43/14Ii 108 5.00 PAID WHiTE:'ApplicantCANARY: Building, ept. PfNK:Treasurer GOLD: File Location ©oNo. a Date NaRTM TOWN OF NORTH ANDOVER w } R ^�.+ Certificate of Occupancy $ �SsAMU5<�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ a� Check # •..� " 14433 ` j' Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING y� ft BUILDING PERNUT NUMBER: DATE ISSUED: /-n29-c"20n / SIGNATURE: C - Building Commissioner/InEeEtor of Buildin2 Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Ln Map Number Parcel Number IAJi 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sf) Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2. Avner of Record arn Name(Print) Address for Service: N Signature Telephone 2.2 Owner of Record: ,Name Print Address for Service: Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ � I � Licensed Construction Supervisor: / License Number { Address Zd� z Expiration Date Signature Telephone 3.2 Registered Home Improvement Cod utr or Not Applicable ❑ CompanylTame , \ Registration Number V C° A ress 7 Expiration.Date Signature Telephone SECTION—4--WORKERS COMPENSATION(NLG.L. C 152 § 25c(6) . Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building rmit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Descrip 'on of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFsFICIA i,US QNI.YI Nit � om leted by permit applicant , r s 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 PlumbinE Building Permit fee(a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief �k2 K I c� 1 Print Name i ignature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 s1r 2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE The Commonwealth of37assachusetts Dgartntent o/IndustrialAccidents -- Office offnvestly2flo c� j 600 Washington Street Boston, Mass. 02111 ? Workers' Compensation Insurance Affidavit name SC 1Qcali n' c A6` t �� cit - phone# i 0 1 am a homeowner performing all work myself. lam a sole proprietor and have no one working in any capacity I O 1 am an employer providing workers' compensation for my employees working on this job. I Company name0 .. r Address f»� i phone insur _. +: otic I am a sole proprietor,general contractor,or homeowner(circle one)and have'hired the contractors listed below who have the following workers' compensation polices: ' f cotnnattti.name. . address j phone# t i_ns-urnrice eor: Mea city. : phone� '1 insurance!coy: poJicX.# �i Failure to secure coverage as required under Section 25A of MGL 152 can lead to the Imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. 1 understand that a copy of this statement maybe forwarded to the Office of investigations of the DIA for coverage verificatinn. I do hereby certify under the pains and rallies of perjury that the information provided above is trite;a1nr1"i:orrect. C � Date 209i Print name Phone# ' official use only do not write in this area to be completed by city or town ofricial i city or town: permitAicense# oBuilding Department pLicensing Board O check if immediate response is required pselectmen's Office (�Ilealth Department contact person: phone#; 00ther Oevieed 3/95-PIA) P.O. Box 111 North Andover, MA 01845 January 24, 2001 CASTRICONE ROOFING AND SIDING 31 Court.Street, North Andover, MA 01845 Dear Mr. Castricone; The estimate you gave me for reroofing the east side of the cottage at Edgewood Farm is approved. I understand the total amount will be $3,500.00 when complete. Please schedule this work as soon as possible, but let me know when you intend to begin so I can alert the residents. Yours truly, 00 Samuel S. Rogers d/b/a Edgewood Farm NORTH Town . of 0 No. O L A E o dower, Mass., COCHICM WICK V ADRATED APa` BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.....30.01.0*/.........T!P.. ..................................... •••: Foundation has permission to ®rect. Q buildings on .. ... 67 Rough tobe occupied as.}.. .��........................... ..4R. ..................r, ..............:............................................. chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws re ating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. 3 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION Sezo TS ELECTRICAL INSPECTOR Rough ....... ... . .. . .. .............................. . Service BUILDING INSPECTOR Final 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 Street No. • SEE REVERSE SIDE . Smoke Det. y ! Date. !.D:.r :�.`u�� 3r°; �►or+rM,"o°L TOWN OF NORTH ANDOVER p PERMIT FOR WIRING .� ter.°•�'�.� i ,SgACNUSE� s + This certifies that .....e.......'7 -- --, .................................... has permission to perform .*- 'f..'....``�-.--�' r wiring in the building of C Mass. ss. at. ........................: ........................c .......... North Andover S" Fee .............. LIc.Noir ���� �...:........... .. �RICIIIOR ELEC Check # I'r,t 8433 v _ Commonwealth of Massachusetts Ofricial Use Only � Permit No. Yy33 -- _ Department of Fire Services Occupancy and Fee Checked BOAR® 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: City or"Town of: NORTH ANDOVER To the Inspector gl'Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street& Number) J�rwl 05-6-,0o0 - Owneror"Tenant -S'0r1Q/-A be.vi-4G Telephone No. Owner's Address 5tiryv is this permit in conjunction withAa 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 Ovet rhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity / Location and Nature of Proposed Electrical Work: (�"4S feta /l Q i- Completion of the folloiving table may be inmved by the Inspector o/Ifir•es. 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 ❑ n- ❑ o.of Emergency Lighting a 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 g No,of Alerting Devices Tons b r No. of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices 4 No. of Dishwashers Space/Area Pleating KW Local❑ Municipal Connection ❑ other No. of Dryers Pleating Appliances �ydt Security Systems:* No.of Devices or Equivalent No. of Water KW No. of No.of Data Wiring: Heaters Signs Ballasts No.of Deviltes or Equivalent No. Hydromassage Bathtubs No.of Motors Total PIP Telecommunications Wiring: No.of Devices or Equivalent OTHER: I Attach additional detail if desired, or as required by the Inspeclor of ll"ires. 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 roof of liability v T p p ry insurance including"completed operation' coverage or its substantial equivalent. Tile undersigned certifies that such C; ND era e is in force,and has exhibited proof of same to the permit issuing Office. CHECK ONE: INSURANCE B ❑ OTHER ❑ (Specify:) 1 certify,under the an andpenalties of9fpnerjury,tltat the iufornzatin�t nEa t/tis t�pplication is trate and complete. FIRM NAME: its i V1 Ai A,— LIC. NO.: Licensee: l5 the Al(I Signatur LIC. NO.:iO4 W (Ifapplicuble. ter " xe. 71pt' in the 1i ense nturrber 1 e.) Blas. Tel. No..-97 td�9 �j - A,ddress: J'. U. ,( C�,V- 115 AX Alt. Tel. No. 7 �` [✓ `'`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, 1 hereby waive this requirement. 1 am the(check one) ❑ owner ❑ owner's agent. Owner/Agent SignatureTelephone No. PERMIT FEE: $ 57 I The Commonwealth of Massachusetts Department of Industrial Accidents l �.. Office of Investigations 600 Washington Street Boston, MA 02111 t'i" www•Ynass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I Please Print LeQibl Name (Business/Organization/Individual): s {+fir— Address: City/State/Zip: NO oitel' "M Phone #: 7 Sr/—kVV—7 kS4 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I an a employer with . 4. ❑ I am a general contractor and I mployees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.9 1 am a sole proprietor or partner- listed on the attached sheet 1 7. ❑ Remodeling 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. ElWe are a corporation and its required.] officers have exercised.their 10: Electrical repairs or additions 3.❑ 1 an a homeowner doing all work right of exemption per MGL 1 I.[] Plumbing repairs or additions myself. [No workers' comp. c. 1.52, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13.0 Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. +Homeowners who submit title-afardevit indicating they arc uu..: r::isork F3ad 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 their workers'comp,policy information. /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: Lic.#: Expiration Date: Job Site Address:,,� City/State/Zip: Attach a copy of the workers' com nsation policy declaration page(showing the policy number and expiration date). .Failure to secure coverage g as required under Section 25A of q 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 under a' and penalti of perjury that the information provided above is true and correct Signature: Phone#: 7 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 S. Plumbing Inspector 6.Other Contact Person: Phone#: i Information and Instructions 1 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." q � 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 tothank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 6I7-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26=05 Fax#617-727-7749 www.rnass.gov/dia