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Date.... ...... .�v......
NORTH{
°f, ;•�"� TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
SSACHU
This certifies that ............ �=yyU--��!. -.....
1/l/ �.E.� .......<<.. .......
has permission to perform ......7f. � f"?.U!!S
.............. ........................................
wiring in the building of..... '!'(... G v5� L L
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at....�n...Cf./.?F.�.��5�.......7.7............. .North Andover,Mass.
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Fee..., 8�.!'. Lic.No.3 41'e c�............. E :E;1�.... . .....
BLE RICALINSPECTOR v
Check N _ �p PERAf
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013" VV!!l!lIVIIWCdIL/I UI 17dJJd�.fI1,IJCl.6J -------- --- ----'
* Permit No.
Department of Fire Services
Occupancy and Fee Checked
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(MEC),5 7 CD4R 12.00
(PLEASE PRINT IN INK OR TYPE ALL EWORMATION) Date: � f t
City or Town of: NORTH ANDOVER To the Inspead of ices:
By this application the undersigned giv s notice o his or her intention to perform the electrical work described below.
Location(Street&Number) / S
Owner or Tenant �i T'eellephone No.
Owner's Address
Is this permit in conjunction with'a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building_ /�j ��1�/iv`io to s -C Utility Authorization No. y,� gg
Existing Service Amps Volts Overhead ❑ Undgrd ❑ No.of Meters
New Service 1 Amps Volts Overhead Undgrd ❑ No. of Meters —L
Number of Feeders and Ampacity V /1/l 1Li,"f 7 01 f/
Location and Nature of Proposed Electrical Work: Alietmil
Completion of the following table may be waived by the Inspector of Wires.
of
No.of Recessed Luminaires No.of Ceil: P•(Paddle) TSusFans TransTotal
rsformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting
rnd. rnd. Batter 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
Tot
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
P Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
Y No.of Devices or Equivalent
No.of Water No.of No.of Data Wiring:
Heaters KW 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: (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 jz�- BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: v t n 4 14 eWS-. C f . LIC.NO.:
Licensee: kl, t1fA ��/7 Signature LIC.NO.: 3 ���,
(If applicable, enter "exempt"in the license number line. Bus.Tel.No.:
Address: Alt.Tel.No.:
*Per M.G.L c.147,s.57-61,security work requires Department of Public Safety"S"License: Lie.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's
Owner/Agent PERMIT FEE: $
Signature Telephone No.
IV
b
The Commonwealth of Massachusetts
Department of Industrial Accidents
e , Office of Investigations
600 Washington Street
Boston,MA 02111
4 >� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lezibly
Name(Business/Organization/Individual): /��t/t I�ren� zc..r. ar C.
Address: ,/
City/State/Zip: �/ijf�� Phone#: 3rs-r-
Are you an employer?Check the appropriate box: Type of project(required):
1.` . "a employer with _ 4. El am a general contractor and I ❑
* have hired the sub-contractors 6. New construction
employees(full and/or part-time).
2.El am a sole proprietor or partner- listed on the attached sheet.t E]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. ❑ 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. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers' 13.❑Other
comp.insurance required.]
*Any applicant that checks box##1 must also fill out the section below showing their workers'compensation policy information.
f 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 Name: tt
Policy#or Self-ins.Lic. Expiration Date: d y I
Job Site Address: /, /7 S5 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 th pa' s and penalties of perjury that the information provided above is true and correct.
Signature: Date: C7
Phone#: 62�5;) 3
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#:
Meetinghouse Commons LLC
115 Carter Field Rd.
North Andover,MA 01845
Phone: 978-687-2635
Fax: 978-689-2310
March 14, 2011
Mr. Peter Murphy, Electrical Inspector
Town of North Andover
Building Department
1600 Osgood Street
North Andover, MA 01845
RE: Electrical Contractor at 6 Ciderpress Way
Dear Pete,
As discussed, we are releasing the previous electrical contractor at 6 Ciderpress Way (building
permit#124-2011),which was Kevin Warren Electrician. This work was completed and
inspected through the rough stage as of September 20, 2010.
We will now continue with the finish portion of the work at this location with Brimac Electric.
Please feel free to contact me with any questions or concerns, or to address any administrative
items.
Sincerely,
omas D. Zahoruiko, Manager
9 i C1
Y J Date......'?.......�............ .....
NORTF/
°tt�``°;•�"� TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
SSA04 SES
This certifies that
has permission to perform .......... //
.,..�d)c W...vJ�L.f....�1 is1i� ..............
wiring in the building of....l."!.P7:. .......... ................
a
at... ... P��...1. !.ZLE2CT�iICI'-,L
, orth Andover,Mass.
Fee IU 21
.................. Lic.No..(..".!!�. . ?............
1 / INSPEM'R
I Check # �/ 1 r �� /� AEQdv/T �.� /
r Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. /�
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07]
Cleave 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 PRINTMTNK OR TYPEALL 1NF0 TION) Date: 1 n
City or Town of: �
By this application the undersi ed gives noTo the Inspector of Wires:
Location(Street c&Number) t' e of his or her intention to perform the electrical work described below.
�
Owner or Tenant ovS
Telephone No.
Owner's Address L_-_�:I tt
Is this permit in conjunction with a building permit? Yes' No ❑ BLDG PERART#
Purpose of Building1(&5 , f2„�1 — Utility Authorization No.
Existing Service Amps _ / Volts Overhead ❑ Und rd
g ❑ No.of Meters
New Service Amps /_Volts Overhead❑ Und rd
g ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Elect ical Work:
� C /4.�
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires -7 No.of Ceil:Susp.(Paddle)Fans No.of Total,
No.of Luminaire Outlets
Transformers KVA,
4 0No.of Hot Tubs
Generators KVA
No. of Luminaires Swimming Pool Above in o.o mergency ig tin
rnd. ❑ rnd. El BatteKy Units g
No. of Receptacle Outlets O No.of Oil Burners FIRE ALARMS No.of Zones
No. of Switches No.of Gas Burners JINO.of Detection and
No. of Ranges No.of Air Cond. Total
InitiatingDevices
Tons No.of Alerting Devices
No. of Waste Disposers Heat Pump Number .Tons KW No.of Self-Contained
Totals: Detection/Alertin Devices
No. of Dishwashers t Space/Area Heating KW Local❑ Municipal
Connection ❑ Other
No. of Dryers Heating Appliances KW Security Systems:*
No. of Water No.of No.of Devices or Equivalent
Heaters KWNo.of
Si ns Ballasts Data Wiring:
No.Hydromassage Bathtubs No.of Devices or E uivalent
No.of Motors Total HP Telecommunications Wiring:
OTHER: No.of Devices or E uivaIent
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value o Electrical Work: Z,:�iD f (When required by municipal policy.)
Work to Start: 3 Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE CO RAGE: 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 cover is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I cert, under the pains and penalties ofperjury,that the information on this application is true and complefe-
FIRM NAME: v�
Licensee: r/1.�,Ckf,ck J NL/�1'�� , ignature LIC.NO.:
(If applicable, ente "exempt"in the license number line.) LIC.NO.�'Z77 JD=
Address: t,t[fa -� �G ?O� Bu.Tel.No.:_I�fSL2B�q
*Per M.G.L.c.147,s.57-61,sec ity work requires Department of Public Safe "S"Licen Alt.Tel.No.: Zfr 7 Sy b L
OWNER'S INSURANCE W R: I am aware that the Licensee does not have the liability insurance No.:
normally
required by law. $y my signature below,I hereby waive this requirement. I am the(check one)❑owner El owner's agent
Owner/Agent
Signature Telephone No. PERMIT FEE: $
ELECTRICAL PERMIT NO. INSPECTION REPORT:
ELECTRICAL INSPECTOR-DOUG SMALL d
r
1.ROUGH INSPECTION:
Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ]
Inspectors'comments:
(Inspectors'Signature-no initials) Date
2.FINAL INSPECTION:
Passed— Failed—[ ] Re-inspection required($50.00)-[ ]
Inspectors'comments:
(Inspectors'Signa u -no m' ials) Date
3.UNDER GROUND INSPECTION:
Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ]
Inspectors'comments:
(Inspectors'Signature-no initials) Date
4.INSPECTION—SERVICE:
DATE CALLED NATIONAL GRID: NAME:
Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ]
Inspectors' comments:
(Inspectors'Signature-no initials) Date
5.INSPECTION-OTHER:
Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ]
Inspectors' comments:
(Inspectors'Signature-no initials) Date
DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED.
The Commonwealth ofMassachusetts
Department of Industrial'.Aceldents
+. Office of Investigations
600 Washington Street
Boston,MA 02111
vww mass govklia
Workers' Compensation Insurance Affidavit: Builders/ContractorsfJElectricians/Plumbe>rs
Applicant information Please Print Legibly
Nanta(B.usiness/Ozganizationdndividual): y1,t •vL A}
Address: ,
City/State/Zip: L .� L49 ST D�.) l klq 0�"8-Phone#:
FE111am
n employer?Check the appropriate box: Type ofproject(required):
a employer with 4. ❑ 1 am a general contractor and I 6. ❑New construction
yees(full and/or p -time).* have hired the sub-contractors
a sole proprietor or partner- listed on the attached sheet.1 7. ❑Remodelingnal have no employees These sub-contractors have 8. ❑Demolition
ng for me in any capacity. workers'comp.insurance. 9. ❑Building addition
orkers'comp,insurance 5• ❑ We are a corporation and ifs10.❑Electrical repairs or additions
ed.] officers have exercised their
homeowner doing all work right of exemption per MGL 11.❑Plumbing_repairs or additions
myself [No workers'comp. c.152,§1(4),and we have no 12,[]Roofxepairs
insurance required.]t employees.(No workers' 13.El Other
comp.insurance required.]
?Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.
Z am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: _T_,- J
Policy#or Self-ins.Lie.#: Expiration Date:
rob Site Address: l 'LL 'L s5 k I City/State/Zip: 00 Q&t 14-t A_
Attach a copy of the workers'compensation policy declar tion 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 STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
X do hereby certo,under the pains andpenalties of perjury that the information provided above is true and correct.
Signature: Date:
a
Phone#:
Official use only. Do not write zn this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.PIumbing inspector
6.Other
c ontactPerson: hone#:
Meetinghouse Commons LLC
115 Carter Field Rd.
North Andover,MA 01845
Phone: 978-687-2635
Fax: 978-689-2310
March 14, 2011
Mr. Peter Murphy, Electrical Inspector
Town of North Andover
Building Department
1600 Osgood Street
North Andover, MA 01845
RE: Electrical Contractor at 6 Cidernress Way
Dear Pete,
As discussed, we are releasing the previous electrical contractor at 6 Ciderpress Way(building
permit#124-2011), which was Kevin Warren Electrician. This work was completed and
inspected through the rough stage as of September 20, 2010.
We will now continue with the finish portion of the work at this location with Brimac Electric.
Please feel free to contact me with any questions or concerns, or to address any administrative
items.
jncSimerely,
as D. Zahoruiko, Manager