HomeMy WebLinkAboutMiscellaneous - 64 FOXHILL ROAD 4/30/2018 64 FOXHILL ROAD
210/037.C-0046-0000.0
B LU U
Ul INO"' FILE
Date. . .7o,'. . ..... .
HORT1y
o? TOWN OF NORTH ANDOVER
D
• - PERMIT FOR GAS INSTALLATION
• 'a
SAGHUSES // 1
r
This certifies that /. . . ." . . . . . . .
has permission for gas installation . , �°. . .. . . !. . .
in the buildings of 11f-Axl I. . . . . . . . . . . . . . . . . . . . . . . . . . . .
at . . .� �!�4 .�. . . . . . . . , North n verb M
Fee. . .7. . '9r� Lic. No. � ! .
GAS INSPECTOR !
Check# / 20
,i;
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
5 — CITY I NORTH ANDOVER MA DATE07125/12 7PERMIT#
JOBSITE ADDRESS 64 FOX HILL RD OWNER'S NAME LHOFFMAN
G --
OWNER ADDRESS TE FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL IE
CLEARLY NEW:Ej RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER ....� _._� ........,��.... �. .w ,� .._..� �...; _..� ..._._...��.. .i.. � �.p.
I
BOOSTER
CONVERSION BURNER
COOK STOVE
IF
L-j
sm a� .,.
DIRECT VENT HEATER
DRYER n._
FIREPLACE ;
FRYOLATOR ,.
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS "
<.
MAKEUP AIR UNIT mW i
OVEN
POOL HEATER
m...,,
ROOM/SPACE HEATER
ROOF TOP UNIT
I .. I 1.. o
TEST ... �I
UNIT HEATER
-
UNVENTED ROOM HEATER`
WATER HEATER
mm
I
OTHEm r tr
..
I .
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES .w' NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND UJI
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 El 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 n accur a to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli v�ata. Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , /` _•!
PLUMBER-GASFITTER NAME I JEFF HUTNICK LICENSE#F15S41TOURE
.: ;.
MPEd— MGF JP Fj JGF U LPGI CORPORATION # 2840 PARTNERSHIP # .m.: LLC[7j#�z. .
COMPANY NAME: CALLAHAN AC&HTG - ADDRESS 91 BELMONT ST
CITY NORTH ANDOVER STATE°M ZIP 1 01844 STEL 97 9 233
FAX _ CELLS EMAIL PLUMBING@CALLAHANAC.COM
Zlie Coialttmonweaitli of massa
ehlrseits
---�• - *, Dc'partment OfIII dllstrialAec•idenis
0tee o,f
i ..ff Ir"Pesti ations
'600;'ttslrington Street
Boston,Ami(02-111
\ 'ar cees' E orupensaiionns>urancia
e Af dart B p ers/ColItf-acl �' }
.-� 3•�Iic�tnt In#•or.�tatio;ii c�xs/�l�.c.tl�ci�trx,/Y lumbers
Nut���' (I3usinessiUr,, �` b'Ycusc pr•iot Legibly
c tnizatioll/Individual :�-��������
drzs T 7 'r" /ilrt�j �, •.a,ii7 ' �12
Clt)'/SLale/Z•p: /. r 1 _, ------- .
Are you au nr to +`� fr Phone #:
e
p )'er.) Check the a
ppropriate box: ---�.—....------ _ ...... ...._.. .. _
Lqd
1 a eu1Plo)'el-with_5-�' 4. [] I am a general contractor and 1
`Type of project(ruluiled):
oyees (full and/or part-tune).* have hired the sub-contractors
a sole proprietor or d• ❑ New col, truct;onpartner- listed on the attached sheet. 7. ❑ Remodel-and have no employees These sub-contractors haveb for me m any capacity• employees and have workers' b. Deolition
I-Norkers' comp. insurance comp. insurance.# 9. ] lsuildinb udditluJl
h 5. [] We are a corporation and its l0.] Electrical rc ails or additiulls
homeowner doing all work officers have exercised thea pf. [No workers' coni 11• Plumb.in�rc gyrus or adcli[ion�
p• right of exemption per MGLb ..p,.tice required.] t c, 152, §1(4),and we have no
12.[] Roofrepails
employees• (No workers' 13.] Odler
.. comp. insurance required.] --- --— -
rt that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t l t�nlw tners Who subtrut this affidavit indicatutg they are doing all work and then hire outside contractors must information.
Submit
x0 onnsetos that check this box must attached an additional sheet showing the name of the sub-contractors and state Gvhether or not th .r
ei jPl')'ces. If the sub-contractors have employees,the must rovide their workers' f th , a new not 111U a indicating such.
Y p os cooties hav
ulYi an employer tftat is roviding P policy number.
irrfvrrrzatiuiz �' rvorkers'compensation insurance for my errtpl'vyees• li clvw is[he policy rirul job si[e
In-tuF. Flee Company Name:
Policy �t or Self-ins. Lic. #:. 14 --
-10b Site Address: �xpuation Date:
Attach a copy e the workers' compensation policy declaration page(showingthe
pohcillnurilbe
allt>re to secure coverage as required under Section 25A of MGL c. 152 c p 3 r and expiration date).
fele up to $1,500.00 and/or one e can lead to the imposition of criminal penalties ol'a
)f up to 5250.00 a da a a y >nlprisotm�ent, as well as civil penalties in the form ima STUD WORK ORDER ues a fine
Y g Inst the violator. Be advised that a copy of this statement may f forwarded to the R ice of
nvestigations °f the DIA for insurance coverage verification.
=1v fierebl certify ander the pains andpenalties o er ur that the information
'° . .fP J y
Provided above is true and correct.
1 i�l la i llf-�:
11)fit# L / Date: /r �2 7 r 2,
.ia1 use vrzly. Do not)write in this area, to be completed by cityor tow -
n official
City or Town:
Issuing one
Authority (circle ): td Pc>nrit/ ,i�ens�
I. board o#'tlealth 2. Btrilding Nepal tment 3. CityPTowa Cleric 4,Electrics
b. ()[her1 Inspector S.Plunrbill .lrlspector•
Contact Person:
Phone#:
Date.........�..............5..............
r►ORTM
TOWN OF NORTH ANDOVER
f T
PERMIT FOR WIRING �
- gsAcnu$�
This certifies that ..........................
�/,�� 19�..... ...............................,...
haspermission to perform ................ ... . . ..........................................................................
". V/
wiring in the building of... .................................................................................
1 ,n
at ..... .f? ... ..1. a`�......! ............................... . ..North Andover,Mass.
Fee...�� ..`..........Lic.No.
........ !.. ...... .........
LEtCAL INSPE R
Check#- 1 o 3Z
O
Commonwealth of Massachusetts ffffiIIcial Use Only
®f Fire ServicesPermit No. ��`1
-T
Department
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07j (leaveblank
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 IN INK OR TYPE ALL INFORM TION) Date: fx �/ / ;�
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned giyeq notice of his or her intention to pethe electrical work described below.
Location(Street&Number) �? Of/�� d
Owner or Tenant Telephone No.
Owner's Address Ap
Is this permit in conjun tion with/a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building -`Z��, 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:
Completion of the following table maybe waived by the Inspector of Wires.
f
,No.of Recessed Luminaires � No.of Ceil: No.oTotal Susp.(Paddle)Fans Transformers KVA \
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool
Above In- El No.of Emergency Lighting
rnd, grnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No,of Zones
of Detection and 1
No.of Switches No.of Gas Burners No. Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices \J
g Tons g R
No.of Waste Disposers Heat Pump Number Tons. . KW No.of Self-Contained
p /�J ..............................................
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
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 Eq
uivalent
OTHER:
Attach additional detail if desired,or as regWred by the Inspector of 97res.
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 cove.-age is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE:,INSURANCE 3 BOND ❑ OTHER ❑ (Specify:)
X certify, acnder tlz ain and penalties of rjury,that the inf9 rmation on this application is true and complete.
FIRM[NA G`T < ;eg UG LIC.NO.:
Licensee: ^f Signature LIC.NO.: L (>
(If applicabl a er " e t"in the lice an�tuber lin . ` Bus.Tel.No.^
Address•,�—� fyUig. L�� ✓a l�� 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's agent.
Owner/Agent PERMIT�'.�EL:$
Signature Telephone No.
c
❑ 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 A=
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.
i
❑ 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 R—Permit/Date Closed: ***Note:Reapply for new permit❑
❑Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass 0 Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
PARTIAL,ROUGH INSPECTION:
Pass 0 Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
n
ROUGH INSPECTION:
Pass V Failed 0 Re-Inspection Required($.) ❑ 4
Inspectors Comments:
Inspectors Signature: U Date:
FINAL.,INSPECTION:
Pass 0 Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
n.
Inspectors Signatur : Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
v
The Commonwealth of Massachusetts
.Department ofIndustrigl Accidents
Office of Investigations
I JV_
600 Washington Street
Boston,MA.02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeAW
Name(Business/Organization/Individual): 5 6 4
Address:s�_L,:�3 W14
City/State/Zip: /�`//�� l/1- OR 60/9Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I a a employer with 4. ❑ I am a general contractor and I `
6. E]New construction
2. 1!mployees(full and/or part-time).* have hired the sub-contractors
a sole proprietor or partner- listed on the attached sheet.# F1 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 1,
3,❑ I am a 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.[]Roof repairs
insurance required.]t employees. [No workers' 13.[__1 Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I Homeowners who submit this affidavit indicating they ire 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:.
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 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
ofpp 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.
1 do hereby c un r the p ins d pen of p jury that the information provided above is true and correct.
Signature: Date:
Phone#:
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#:
43
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 ofhire,
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-insuranceice se
1 n 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 multiplepermit/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 ant as proof that a valid affidavit is on file for future permits or licenses. Anew 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 oUndustrial Accidents
Office of Investigations
600 Washington Street
Boston}MA 02111
Tel,#617-727-4900 ext.406 or 1-877rM.ASSAFE
Revised 5-26-05 Fax#617-727-7749
www-nass,gov/dia
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09868 , Date .I: .I-� . . . . .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that . . �? t)a_, ,,,RA 5 . . . . . . . .
has permission to perform . .
plumbing in the buildings of . . . . . . . . . . . . . . . .
at . . . ..��, . ... . . . . . . . . . . . North Andover, Mass.
Fee 4 t t' . . Lic. No.'�22I).J . . . MV . . . . . . . . . . . . . . . . . . . . .
PLUMBING INSPECTOR
Check# 2 3j
w
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY UL'1 MA DATE / /C3 1 PERMIT#
JOBSITE ADDRESS _ �=O 1 ll _7W _— OWNER'S NAME[.
jr OWNER ADDRESS i TEL — FAX E
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUC NAL RESIDENTIAL DJ
PRINT
CLEARLY NEW: RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES® NOD
FIXTURES 7 FLOOR- BSM 1 2"" —`3, , 4 5 6 7 8 9 10 11 12 13 14
BATHTUB �� _ _f __ I .__ _..._1 ! �I _-._._._..-.► ._ ! .-_.._.._._ _ ! _.-___.G i _ ( __i
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM ! f --J
DEDICATED GREASE SYSTEM ___..-....I ( _...I ... .. ....1 ._.._.__! _......._.I 1 _-__...._I
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER . I ._.. J.__...,A ..___._I _._.._._! _._._-! _.___I
DRINKING FOUNTAIN
_ j=
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) I
KITCHEN SINK ! _ I .._i _. f ! �( .__. __.I _ _. .I ! ! .......__! _...._._J
LAVATORY __.___! ___.___J ._._.__._I __..__._.( ____.___! __..-._.._I _..._.._..I ---____I .__.____.-I ._..__J ._...____! _.._..._.._f .__._! _ ► _______l
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASH#NG MACHINE CONNECTION
WATER HE } ( i
ATER ALL TYPES
WATER PIPING
OTHER .........
i f
}
INSURANCE COVERAGE: .
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY Q 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 ONEDNLY: . OWNER i AGENT 10
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 bq my know ge
and that all plumbing work and installations performed under the permit issued for this application will be in cnce with t pr vision
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. d
PLUMBER'S NAME �C% ILICENSE# IGNATU
MP JP�f_I CORPORATION[0# ` PARTNERSHIP M#=LLC __I
COMPANY NAME \
ADDRESS L
CITY fjC� �S STATE iLL 1 ZIP TEL
- -- ---- --FAX ; CELL _f EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
y THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
The Commonwealth of Massachusetts
Department of IndustriqlAccidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Ley ibly
Name(Business/Organization/Individual): (�'—� G�c-f S
Address: � � C4 �'� A0 L
City/State/Zip: �� d S 4A 191 qD 6 Phone#: ` � d2�/-�1�'��•
Are you a mployer?Check the appropriate box: Type of project(required):
1. am a employer with 4. ❑ I am a general contractor and I 6. ❑New struction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.1 7• g1femodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. g, ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a 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.❑Roof repairs
insurance required.]t employees.[No workers'
comp.insurance required.] 1311 other
*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 aie 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. A4X_4(19_
Insurance Company Name:.
Policy#or Self-ins.Lie.#: 00S_O0es V7 7 77 Expiration Date:
Job Site Address: .e5 T' 0 X //7// Rtj� City/State/Zip: 1111x '&
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder 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 certi u d tTze pai tie of jury that the information provided ab ve 's`true and correct. -
Si ature: j7 Date: 41111
l
Phone#: /
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#:
cn
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 ofhire,-
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 orermit too operate a business or to construct p p r buildings in the commonwealth for any
applicant who has not producedacceptable 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 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 Iadustrial.Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel,#617-727-4900 ext 406 or 1-8777MASSAFB
Revised 5-26-05
Fax#617-727-7749
wwwmass.gov/dia
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PERMIT FOR WIRING
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10871
CQwanc irwealth, of Massachusetts Official Use Only
Department of Fire Services Permit No. /G 7-1
Occupancy and Fee Checked
-= BOARD OF FIRE PREVENITK`t� REGULATIOP'f [Rev. 9/05] (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 TY��/AL INFORMATION) Date: (P�t t f d-
City or Town of. Iy' dQ�Q/lr To the Inspector of Wires:
B this application Ircation the
By undersigned ryes notice of his s or her intention to e
1� g perform the electrical work described below.
Location(Street&Number)
Owner or Tenant A V1 Telephone No.
Owner's Address
Is this permit in conjunction with a buildingpermit? Yes
P ❑ No' ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps = / +'olts Overhead U Und rd
g 0 No.of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion of thefollowing table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans o.of Tota
X Transformers KVA
s No. of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool A ove ❑ In- ❑ o.of Emergency ig ng
rnd. rid. Batte Units
No. of Receptacle Outlets No.of Oil BurnersFHtE ALARMS No.of Zones
No.of Switches No. of Gas Burners No. of Detection an
Initiating Devices
No.of Ranges No. of Air Cond. Total Tons No. of Alerting Devices
No.of Waste Disposers eat Pump Number ons o. of Self-Contained-
Totals: I I Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ unicipa ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
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No.of Devices or Equivalent
No.of
Heaters KW o.of o'o _ Data Wiring:
Signs _ .-- Ball^sts No.of Devices or E uivalent
!* No.Hydromassage Bathtubs _ No.of Motors Total HP TelecommunicationsWiring:
No.of Devices 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 wi"C 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 liabi ' insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such col -age is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify, under thepains and penalties o erjury, that-the information on this application is true and complete.
FIRM N wJt4e
LIC. 0:: I Owl 63%
Licensee: ignature LIC.NO.:
(If applic en t "ex t , - t rue ber ne.) Bus:Tel.No..
2M IV r
Addres . Alt.Tel.No.:
*Security ystem Contractor License required for this work;if applicable,enter the license number here:
OWNERIS INSURANCE«-'RIVER: I am aware that the Licensee does not have the liability insurance co age normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑ owner` ❑ owner's agent.
Owner/Agent — -----_
Signature Telephone No. PERMIT FEE. $
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