HomeMy WebLinkAboutMiscellaneous - 575 TURNPIKE STREET 4/30/2018 (5)............
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
VA,
Thiscertifies that ....................................................... ...........................................
O..
has permission to perform ................... j
.......6 I .......tA........ ......... ............
wiringin the building of ............................... 1: .............................................................................
at ... 7-6- T, /,Z&th Andover, Mass.
............. , .......................................................................... .
Fee.. . . ... .... Lic. No.
.
................. ........ . ........... ....
A— f 12 ....................
ELECTRICINSPECTOR.
Check #
12254
4 Commonwealth of Massachusetts
Department of Fire Services
, BOARD OF FIRE PREVENTION REGULATIONS
l
.1%APPLICATION FOR 1PErRMIT dance with TO�PERFOe MsachusettscRcM al ELCode(�ECTRQ, 527 �C�A oWORAllwo to be nerformedK
A (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date:
M 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 � J 1 U A' JP � � 213, T!
3 Owner or Tenant i Xns N '
Owner's Address
Is this permit in conj nction with a building permit? Ys [j No 9
Official Use my
Permit No.
Occupancy and Fee Checked
[Rev. 1/071(leave blank
a
w
Telephone No.
(Check Appropriate Box)
Purpose of Building I IV L -Lr (,0 Pi 1t F1 - C .IA-&.) Utility Authorization No.
- Existing Service Amps / Volts Overhead ❑ Undgrd ❑
New Service Amps / Volts Overhead ❑ Undgrd ❑
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: T --C pL A `e ¢1 CA% PU M'P
No. of Meters
No. of Meters
Completion ofthe following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans v
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- ❑
rnd. rnd.
o. o mergency Lighting
Batteryits
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
g
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Dis posers
p
Heat Pump
Totals:
N_ umber -1--
Tons
* -
KW
...................._.
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
p g
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
security c rev or E uivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or E uivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of -Wires.
Estimated Value of Electrical Work: aoc , "'' (When required by municipal policy.)
Work to Start: 3' a7 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 El(Specify:)
I certify, under the p ains and p nalties of perjury, that the in forntation on this application is true and complete.
FIRM NAME) ROi U Rn vY®01t't.3 Ary LL� LIC. NO.:
K)
11
Z
Q%,
Licensee: —06-4np !--oVYoUtm IIA,-' Signat NO.:
(If applicable, e r " xempt', in the�ense,ly1rrcbe�ine.) r Bus. Tel. No.: l 56 6 S?�
Address: � 4 V l/ ° �C��¢0�G � ' Q` �(� Ci 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
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner!g 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 a
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed J
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an /
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall -be limited as to the time of ongoing construction activity, and 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 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments: -
Inspectors Signature:
Date:
PARTIAL, ROUGH INSPECTION:
Pass E
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INS
Pass
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
DEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department ofIndustrial Accidents
Office of Investigations
kvi 600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Informationj,____ Please Print Legib
ly
Name (Business/Organization/Individual i FS (.®y'70 0 A 3 I AAi ,
Address: ( 7 t6luflli_ ro,
City/State/Zip: � r 264tD�6 ° ''� ` Ol$G `� Phone #: ��` ' 6� •��%�
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. ❑ New construction
,emplo-yees (full and/or part-time)
have hired the sub -contractors
listed the
Remodeling
2 am a sole proprietor or partner-
on attached sheet.
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.
9. ❑ Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
ical repairs or additions
required.]
officers have exercised their
3. F1 am a homeowner doing all work
right of exemption per MGL
.❑ Plumbing repairs or additions
myself. [No workers' comp.
c. 152, §1(4), and we have no
12.❑ Roofrepairs
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.
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 -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company
Policy # or Self -ins. Lic.
Job Site Address:
Expiration Date:
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 certify under /Ilties of perjury that the information provided above is true and correct.
e;...,�fi .cel ( �• � � � 7
Phone # 129 1 9
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 #•
9
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-contractor(s) 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 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.ofMassachusetts
Department of Industrial Accidents.
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877rMASSAFB
Revised 5-26-05 Fay, # 617-727-7749
wvvw.Mass,govldia
ocation V5,2
Date -7-.45t Z
N°"7" TOWN OF NORTH ANDOVER
F p Certificate of Occupancy $ f
# y
Building/Frame Permit Fee
'sJACK uSEt� Foundation Permit Fee
-�,-70ther Permit Fee $ *D
�f^W r ` ` "' Viewer Connection Fee $ ___.......__-...
Water Connection Fee $
TOTAL $' Zfi'a
'JUL 1 5 1993
Building Inspector
11- 6214 Div. Public Works
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT:
APPLICANT: .i 1 s �oac CzI (i ��hon
t1 Kik- 2-S s-75- St
LOCATION: Assessor's Map Number Parcel
Subdivision Lots) .
Street
St. Number
************************Official Use only************************
RECOM14ENDATIONS OF TOWN AGENTS:
Conservation Administrator
Comments
Town Planner
Comments
Food Inspector -Health
Septic Inspector -Health
Comments
Public Works - sewer/water connections
dor
XFire
J
- drivewwayy p-e7(,
i
Department �e� `
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Received by Building Inspector Date
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of (famriTIII mraith t f ffiasItt Permit No.
a le;Itri'iMMt. af-11tibur Occupancy & Fee Checked
r BOARD OF FIRE PRVF.N*nON REGULATIONS 527 C&IR 12:00 ° peeve blank) p3Z`�'g
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts E?ectricai Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date ._.6� — 7
MIXT or Town of NORTH ANDOVER To the Inspector of Wires:
The udersigned applies for a permit to perform the electrical work described below.
Lccation (Street & Numbed' / y Pi 1�f- -
Owner or Tenant `7 0 A AJ v I TL,AI
Owner's Address
ts this permit in ccnjunc:icn with a buiiding permit: Yes _ No (Check Appropriate Box)
Purecse of Butidina Utility Authcrization No.
Exis-,inc Service Ames Vcits CVerneac Unccrnc ! No. of Meters
r— r
New Service .Amps Volts Overhead _ Unccr^c ._
No. of Meters
Numcer of Feecers ane Ampacity
Lccancn ane Nature of -. _cosec Eiec: cZ: :1crx
Total
Nc. _ _ _ ,:r.g CUuets No. o. r,,. =cs No. _. -anstormers K:'A
ne Fixture
No. of Llcrvtt/�) _ Atcve= tn-
lJ Swtm rtr.c =cot Gar.eratcrs KVA
No. at Emergency Lighting
No. of =___o..ectac:e Cutlets No. c. 0'1Burners Barter., Units
I i _
iF.c
No. of Switch Cutlets Ne. o. Gas 8_...ers rAL-.RMS No. of acnes
Totat No. of Cetecnon anc
No. ct Rances tNo. c. Air C .crs ( intuat:nc Cevices
ea: '::at Total
No. cf Ciscosais Noor Pumcs:! No. at Scuncing Cevtces
No. of Sart Containec
No. of.Cisnwasners Scace Area -!eating cv I Detec::cniSouncing Devices
Muntcicat
No. of Dryers Hea me Devices cv I Local Connec•:en _Other
No. of NO. of I Law Vc::age
No. of .Vater Heaters KN Sicns Sailasts W;r:nc
No. i-ivcro Massace '% s � No. of Mczcrs C:at H.
%rl
INSURANCE CC`1ERAGE. Pursuant :a the recuirerr.ents ar .1assacncsers ;er.erat Laws
I have a current Ltaeiiity Insurance Policy +nc:uc:ng C etec Ccerarens Coverage or its sucstantial ecutvaient. YES NO _ l
have SUemtttec vati prcot ct same t0 the �;,ttio9- YE3v NO _ I! you nave checxec YES. please inoicate the typ of coverage ay
ottecxing :he a nate Dox.
INSURANCE ik BONO — OTHE= = (Please Scec:`y)
(Exotrauon Date)
Est:matec Value of E:ec:ncai 'NorK S T
Wcrx :o Star, inseec::en Cato Ra"astag: Rough
nal �/
Signec uncar "j�%ai-es of p �ry: �GJ „ , _ OQC -.1 /2—
=:R%1 NAME /-* G UC.
Licensee ��� 2l�!✓�e_ I7y�V vvY`-
. � Bus. :at. No.
AOQress r (,� Att. 'eJ.. No.
re -
OWNER'S INSURANCE'NAtVEP: I aware that he ' censea Ices not wave :no insurance coverage or its suostanttal ecutvaient as cuireo ov Massachusetts General laws. ane that my s:gnature an :n:s cerr :t acoticatton waives this reowrement. Owner Agent
;Please cnecx one)
:eiecrone No. PEFPMIT FEE S
iSicr.ature of Cwner or Agenn i�55@
��-,-,+n��a-: ., _ .. ,;,�^srY-+�-•-e-Y;rx.3�i yY4'�+'..a�,.�;.:v�'F��s�e-i=4/t*., -.:. �.: " �..'-Cww2�»., _..,._.
_ Date. ....... .' .
727 '.
pORT11 -Y _
TOWN OF NORTH ANbOVER A
PERMIT FOR WIRING
,SSACNus� 1
i
F
This `certifies that .... z ......��
has permission to perform .... .............(
61
wiring'in.the building ofG.1---....,/..t r��,� ? ;
1 _ o
.. P2
at ..... ..S�. ... iL��n. L,c .....,J'),�>............. . North Andover, Mass.o
Fee ...... ).0........... Lic. No%/.I'..lrJ J/C...................................
ELECTRICAL INSPECTOR _
WiiITE: Applicant CANARY:. Building Dept.
PINK: Treasurer -.