HomeMy WebLinkAboutMiscellaneous - 66 JEFFERSON STREET 4/30/2018 66 JEFFERSON STREET
210/023.0-00040061.H
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Date.2......0..........
TOWN OF NORTH ANDOVER
3: ....
p PERM
-
PERMIT FOR WIRING
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This certifies that ....6,91,
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....... ....................... . ............................
has permission to perform AA- .4"e"14
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wiring in the building ...................
jit.. ... ............ .......... ...... North Andover,Mass.
Fee.:.....A�....... Li/c. . .......... ........... .. .... ....
No—ve, .............
Check #
88 7
Commonwealth of Massachusetts official Use Only
Department of Fire Services Permit No.
BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked
[Rev. 1/07] (leaveblank
APPLICATION FOR PERMIT TO PERFORM ELEPTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code( C), 7 CMR 12.00
(PLEASEPRINTINIAW OR TYPE ALL INFORMATION) Date:
City or Town of: NORTHANDOVER R To.the
Ins ctor f Wires:
By this application the undersigned gi s cecs or h r intention perform the electrical work described below.
Location(Street&Number) t1117k�
Owner or Tenant 1� }2 v Ea27—v Telephone No.
Owner's Address 1,
Is this permit in conjunction with a buil npermit? Yes No
❑ (Check Appropriate Box)
Purpose of Building tility Authorization No.
Existing Service rd Amps / Volts Overhe d ❑ Und
g ❑ No.of Meters
New Service Amps / Volts Overhead
❑ Undgrd ❑ No,of Meters
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work:
Com letion o the ollowin table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans NO.of Total .
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Ab �ove In- o,o mergency g
.
-- No.of Receptacle Outsets No.of Oil Burners rndBatte -Units MFIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
No.of Ranges
InitiatingDevices
No.of Air Cond. TonTots No.of Alerting Devices
M No.of Waste Disposers Heat Pump clamber Tons KW o.of Self-Contained
Totals:
.. ..-........... -................� Detection/Alertin Devices
1 No.of Dishwashers Space/Area HeatingKW Municipal
Loeal❑ Connection Other
No.of Dryers Heating Appliances KW Security Systems:*
No.of WaterNo.of No.of No.of Devices or Equivalent
Heaters KW Si s Ballasts . Data Wiring:
No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total Hp Telecommunications Wiring:
No.of Devices or Equivalent
OTHER: -
21 1
�„ Attach additional detail if desired,or as required by the Inspector of Wires.
1 Estimated Value of Electrical Work: 'Zo m- (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 permi ' suing office.
CHECK ONE: INSURANCE ❑ BOND
❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this lic ' n ' and complete.
FIRM NAME:
Licensee: Signatfire LIC.NO.:
(If applicable, enter"exempt"in the license num r line)
Address: i us.Tel.No.:
*Per M.G.L c. 147,s. 57-61,securi work requires Department of Public Safety"S"License: Alt.Tel.No.•Lic.No.
OWNER'S INS R: I a n
aware that the Licensee does not have the liability insurance coverage normally
required by law. By y i a belo ,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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The Commonwealth of Massachusetts
k� I Department of Industrial Accidents
Office of Investigations
yj U 600 Washington Street
Boston, MA 02111
www.mwsgov/dia .
Workers' Compensation Insurance Affidavit: Bailders/Contractors/Electricians/Plumbers
Aaalicant Information Please Print Legibly
Name (Business/organization/individual):
Address:
City/Sta Zip: Phone#: .
Are u an employer?Check-the appropriate box: T fProjectr uir
1. I am a employer with 4, ❑ I am a general contractor and I ' of ( � te•
employees(full and/or part-time),* have hired the sub-contractors 6 ❑New construction
2.❑ I am a:sole proprietor or partner- listed on the attached sheet,t 7• ❑Remodeling
ship and have no employees These sults-contractors have 8. ❑Demolition
working for me.in any capacity• workers' comp.insurance. q• ❑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.❑ Plumbing repairs or additions
myself.[No-work ers'comp, c. 1.52, §1(4),'and we have no 12.M Roof
repairsinsurance're uired]t employees. [No workers'
comp. insurance required-] 13•❑Other
*Any applicant that checks bort#t must etso fill out the section below showing their worker'oom
pensatiorpolicy information•
t Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such.
4contractors that check this box mustattaehed an additional sheet showing the frame of the sub-contractors and their workers'comp_policy information.
lam an employer that is.provuhng workers'compensation insurance for my employees: Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Y
Job Site Address: City/State/Zip: .
Attach a copy of the workers' compensation iicy 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.
.1 I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: Date
Phone#:
Ofj°ici:Athl
y. Do not write in this area,to be completed by city or town ofcial
City oPermit/License#
Issuinity(circle one):
1. Boalth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector6.OthContac ; Phone#:
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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." f
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 tmstee 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 cant'workers'compensation insurance. IfanLLC 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 atridavit. 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 nurnber listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
V
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 contactyou regarding the applicam
Please be sure to fill in the permit/license number which Krill 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 Industrial Accidents
Office of 1mvestigations
600 Washington Street
Boston, X4A 02111
Tel.#617-7274900 ext 406 or 1-8.77-MASSAFB
Fax#617-727-774
Revised 5-26-115 www_mass.gov/dia
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Commonwealth of Massachusetts OF 'f_ G i RlCi�fUS
k DpnGon:of Registration l�lS �dE "7 . ►� VNiEC?` 1C�
T Board oflectn l Cxaimriers tSttSrt5 tIGENSE T
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JAMES
MICHAEL—*.COTTER � E S �QTT;E R
20 GURCZAK--1U -
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Master Electrician
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License No. Expiration Date. ' Serial No
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Date.....
........ ......... .....
NORTH
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............../..............H....0. 1YAl' IF-e
. . ..........
...............
has permission to perform ......... .
wiring in the building of........... ..Z.4)...............................
at.............................. P.
. ....................... ...... .North Andover,Mass.
Fee..41�'�7� .... Lic.Noj..I�.49-jk...... ..... .. .....
ELECTRICAL INSPECP6R
Check #
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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),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 7 — 7 — /0
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned ives notice of his or he int tion to perform the electrical work described below.
Location(Street&Number)
Owner or Tenant CQ'/' yvt u a Telephone No.
Owner's Address S'L�l�j�
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building 4&S, -eco 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 may be waived by the Inspector of Wires.
of
No.of Recessed Luminaires No.of Ceil: TransSusp.(Paddle)Fans Total
Trsformers KVA
" No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- E:1o.o Emergency ig mg
rnd. rnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons g
No.of Waste Disposers Heat Pump I.NR I Tons J.KW No.of Self-Contained
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 WaterKW No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
$ Telecommunications Wiring:
--
No.Hydromassage Bathtubs T.of Motors Total HP No.of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the .�o Inspector Wires.
P
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 ❑ BOND ❑ OTHER ❑ (Specify:)
I certify,under the ins a d penal ' of pe 'ury,Ma the informationon this application is true and complete.
FIRM NAME: Z /'e Ct/nP N` G oaf LIC.NO.:
Licensee: Signature LIC.NO.
(If app licable,enter 11e�gmpt"in t 1•cense mber ling) Bus.Tel.No.• 7
Address: Olvef M Alt.Tel.No.:?/ —
*Per M.G.L c. 147,s. 57-61,security work requires Blepartment 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
Owner/Agent FPE"IT FEE. $
Signature Telephone No.
r 1
.yL
1
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
s� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address:__
City/State/Zip: 1-1nr5 --0r V QIF/Phone
Are yo"n 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
employees(full and/or p&t-time).* have hired the sub-contractors
2.❑ I am a sole p P ro rietor or partner- listed on the attached sheet.
1 7. 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.El Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.E]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#I 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 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
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 t :der the ains penalties ofp_ erjury hat the information provided above is true and correct.
Sifznature: Date:
Phone#: 7 eFY -99
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#: