Loading...
HomeMy WebLinkAboutMiscellaneous - 67 GREEN HILL AVENUE 4/30/2018 OMMUM 67 GREEN HILL AVENUE 210/022._ 0_0000.0 Date...1..P./l.la.`/.._5"..... 11392 o�"OpT"'tio TOWN OF NORTH ANDOVER ° ` 9 PERMIT FOR PLUMBING CHU lt�d-4�4J .4his certifies that.:.......... !'.............................................................................................. ha p. to perform... . ........................� lumbm -in the buildings of... .4 ;... ...�. 1 at..........,......:.. :............... � ...f...., ✓ -..............., North Andover, Mass. Fee .Lic. No.OV PLUMBING INSPECTOR Check# 1� td ( C MASSACHUSETTS UNIFORM APPLICATION FOR A P RMIT TO PERFORM PLUMBING WORK + CITY MA DATE PERMIT# II JOBSITE ADDRESS Cr-Z G{VLre.L"iu— OWNER'S NAME nigv `IIIA OWNER ADDRESS TEL aft FAX i TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL�^ •4 PRINT ' CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑ t FIXTURES Z FLOOR BSM 1 2 3 4 5_ 6 7 B 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM 1 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE 1 MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES i WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE OF INDEMNITY ❑ BOND ❑ 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 ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information 1 have submitted or entered regarding this application _ o the best of my knov�ledge and that all plumbing work and installations performed under the permit issued for this application w" a in co plian II rtinenl provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# C"1C SIG ATURE MP❑ JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME � ADDRESS 6-7 CITYSTATE ZIP LA(5 TEL "-A �� ��z � ' 5A CELL EMAIL 6V 6i1 " VA ,Cd The Commonwealth of Massachusetts Deparanent of lit dustrialAcciden6 Office of Investlgatloils r GOO ashington Street al Boston, MA 02111 . ..... iviv>iv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers .pplicant Information Please Print Legibly fame (Business/Organization/Individual): .ddress: ity/State/Zip: , Phone#: •e you an employer? Checic the appropriate box: Type of project(required): ] I am a employer with 4. ❑ I am a general contractor and I 6. ❑New consmietion employees(full and/or part-time).* have hired the sub-contractors ] I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' Y P tY• 9. ❑ Building addition I [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.EJ Electrical repairs or additions } officers have exercised their t ] I am a homeowner doing all work I I.❑ Plumbing repairs or additions myself_ [No workers' comp. right of exemption per MGL 12.[:] Roof repairs insurance required.] � c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] `applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. neowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tractors that check this box must attached an additional sheet showing the name of the sub-contractors*and state whether or not those entities have i oyees. if the sub-contractors have employees,they must provide their workers'comp.policy number. z an employer that isproviding workers'compensation insu;ante for inv employees. Below is thepo/icy acrd job site rmation. ranee Company Name: cy# or Self-ins. Lic. #: Expiration Date: Site Address: City/State/Zip: ich a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 p to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of .stigations of the DIA for insurance coverage verification. hereby certify ander the pains and penalties of perjury that the information provided above is true and correct. iature: Date: ne 4: ?fficirrl rise only. Do not write in this areb,to be completed by city or town of ::ity or Town: Permit/License# issuing Authority (circle one): L hoard of Health 2. Building Department 3. City/Town Cleric 4.Electrical Inspector 5. Piumbiug Inspector S. Other DateA) ................ OF 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION CHU Thiscertifies that .............................................I..........I..................................................... has permission for gas in t flation ........................................................................... . in the buildinM of ..L7� ......... -4.............. at...6.7..........L-)�.......................................................... North Andover, Mass. Fee.(>ZO)....... Lic. No. .10('�V. ..................... ................ GASINSPECTOR Check# 10204 p U MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY �A ©C:t MA DATE ��''PERMIT# JOBSITE ADDRESS Cpl ZMgel,1--Lu-. e tOp OWNER'S NAME ' OWNER ADDRESS TEL ` -7 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATI RE CEMENT: PLANS SUBMITTED: YES NO , APPLIANCES Z FLOORS— BSM 1 2 3 4 5 b 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER { INSURANCE COVERAGE 1 havle a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I 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 : OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insura me coverage requkW by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit appkation waives this requirement. CHECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR AGENT I hereby certity that all of the derails and information I have submitted or entered regarding this are tnre and best of my knowledge and that all pkwr"V Mork and installations performed under eve Derma issued for this application in com t Provision of the Massachusetts Stale Pkonbirg Code 142 the General Laws. PLUMBER-GASFITTER NAME 0 LICENSE# TURE __ M MGF JP JGF LPGI ORPORATION # PARTNERSHIP # LLC # V1 COMPANY NAME: 4 "-Ck- ADDRESS S-7 CITY Ufti -T�� n-- ST TE' ZIP FAX q76 5Z7 CELL EMAIL l( V-0 M,50 i ,per �-\ Tit a Commonwealth of Massachusetts usetts ` Department of Industrial Accidents r S 1 Congress Street,Suite 100 Boston,M4 02114-2017 www massgov/dia 'Yorkers'Compewation Insurance Affidsvit:Builders/Contractors/EledricianstPlumben. TO BE FLED WITH THE PERWrMG A1fTHORM. Apylkant Information I PlIew print Name (B d Address: t-- 1 Phone #: �� H 11; City/StatelZip: �YL�(O�'✓ �. ` Ars mpMyert Cheep tie apprepriate bes: Type of project(required): 1 l. .m,employer wAb_an0oytxa(fill aWor pw-inwl- 7. ❑New construction 2.E]1 em a sok proprietor a pwvxnbip and here no cnwioyen working for me in E. Remodeling any_ih-(No waters'comp int— -Wired-) t 9. ❑Demolition 1 3.D 1 am a homeowner doing aD wort mywlf(No wortas'comp-ir-x cc mg�ed-1 10 Butkitag addition 4.D 1 am a hmwowna and wal be biriig Contractor toco v&xi an wat on my property. 1 will anwe drat an Convacion ci&a have weetc"'compuzaoon itstrarwe or ac sok 11.❑Electrical repairs or additions wi>d no aa'doyam 12.Q Phrmbing repairs or additions s. I am•gpotaal Conoacwr nd 1 hors hired the scab-eonoacu"bstod on the attached Ower 13.D Roof repairs 4 These Ab cwaacwn base employees mod bevc wadwn'Comp.inSwwwc.t 14.Q Other 6.D We sm a Corpors600 and as offlem hate c=aciwd their nigh of exempum pa MGL c. s 152,;1(4X and we have no employees:Rio waken'Comp-izRvance rogrmod 1 t -Any applicant that dwcks boot II mtw also Lill oa the soetion below Aawring dutir waters'comgana600 policy information t tlowwwom who submit des at6dw*mdintat thcy we doing an war gad din hire outside couomam must submit a new atbdova i>dwaitg mch 1 tConuwkws that shed this bot mum attached m mdditiaW shoes showing tri Daae of the snb-Cortractors ad awe whether Of not those c titim hors J ®pioyeef, If the at cwwactors have eapioyocr.they googol provide their —d—'comp po+icy mamba. I am an employer that is providing worAm'eongmnsadon insurancefor try employem Bdow isthe pollcp and job sift btformadon. Insurance Company Name: { Policy g or Self--ins.Lic.tt: mon Date: l Job Site Address: Crty/StactJLp: Attach a copy of the worllen,compensation policy dedaradoe page(showing the poKcy amber and eipiratlor date). Faihm to secure coverage as required under MGL c. 152,125A is a criminal violation punishable by a fine up to$1,500.00 and/or ono-ycar impruotuncat.as wen as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for iosuraace s coverage verification. ' ! I do hereby and penauia of p#ury that the informadon provided b and cuomai I 1 i Ofilckd use only. Do not write in this area,to be c»nipleted by city or town o %ddt City or Town: Permit/License 0 { Issuing Authority(circle one): I' Department 3.Ci /Town Clerk 4.Elettrial Inspector S.Plumbing Inspector I.Board of Health 2.Bru7dieg Dep ty P� i 6.Other Contact Person: Phone 0: ? y, COMMONWEALTH OF MASSACHUSETTS 0 ' ASF ITT i J.ES TN'E FOLL0 :CENSE 4 CEVSE AS A MASTER PL{UMBE4 I'AUi D HOFFMAN t f: y 3� REv1iE ;S"( �P"A--Ffj 0 01835 7?�9 ` Date.4,�At.%+................ Of TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that RA.1``.'�� e � has permission for gas installatio in the buildings of....... 0 ...............V.....y-N......................................................................................... at... North Andover, Mass. .................................................................... Fee .-.00... Lic. No. �� / GAS INSPECTOR Check#6 6�og . . 9260 a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I North Andover MA DATE 411512014 PERMIT# D JOBSITE ADDRESSI 67 Green Hill Ave OWNER'S NAME to -1Q- GOWNER ADDRESS ITEL - FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[j EDUCATIONAL® RESIDENTIALE] PRINT CLEARLY NEW: RENOVATION:Ej REPLACEMENT: PLANS SUBMITTED: YES® NO APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE E DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER RQOM I SPACE HEATER RGOF TOP UNIT TEST MIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER ----------------- ------------------ Replace 1 Gas Meter x and Piping as Needed INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE INDEMNITY ® BOND El 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 ® 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 ue 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 m Iiance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Joseph Marino LICENSE# 8736 'SIGNATURE MP ED MGF® JP JGF LPGI® CORPORATION Ej# 3285C PART SHIP # LLC®# COMPANY NAME:j RH White Construction Co ADDRESS 41 Central St CITY Auburn STATE=ZIP 01501 TEL 508)832-3295 FAX 1508-926-4347 j CELL 508 832 4614 EMAIL IMarinoa@RHWhite.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# � � PLAN REVIEW NOTES O'iVi11fEAL.TH OF MASS&CFi9U --—_ RSAND BASF Y D AS F...Ma-LATER P, fiiIh3R `":x UES TF?S`AHC2UE1iCfiNSE l M'A-$.I N O - _=:c• ,; ✓r . A'R_R;-I'NGTf1N ST ._ _ -• -. _ - �: / -'�W`f3�R_GE-S-TER MA 0 a 05/07./14 __C,Oi1)iro )tfWEALTH OF MASSACd 3:S TfS :;•;:;-t PGU1ti1I�f3ERS AND GASFITTRS t= "l('CENSE'Q AS A JOU.RNE1liVIAN=�?L111 I TSSVES THE ABOVEtLICENSE 3"'Fi4RR2=NGTON ST• - --_ : U7 Tl ST Cd0�� -A-- R ; _.. _ A a:�=:: 05101/3+4 i I - UY! U.!! LUl' L` .U'Y ...IUVV...1LV!J1 1\I1 WI It1L VVI1VII\VVI 1 1-IVL VL/ UL I ACQR�® +� CERTIFICATE OF LIABILITYINSURANCEpage 1 oQ 08/29/2013 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions ofthe policy,certain policies may require an endorsement.A statement on this certifleate does notconferrights to the certif7c2te holder in lieu of such endorsement(s). PRODUCER CONTACT Williq pt hIAMP Massachusetts, Inc. PHONE C/o 26 contury Blvd. NO j )- 877-945'-7378 FAx.No)_ 888_46_772378 R. 0. Box 305191 -MAIL N19hville, TN 37230-5191 D.DR65,s cextificatp-pr.willis.GOm INSURER(8)AFFORDINGCOVERAGE NAICtr INSURED INBURERA:The ChAztAs Oak rizA IneuranoG COmpauy 25615-001 R. H. White Construction Company, Inc. INSURERS;Trava:Lnrs Property Casualty COMPany of Am 25674-003 41 Central Street INSURER C:HAtiOnA1 Union Piro) Tneuranea P. 0. Box 257 Company Of 79445-001 Auburn, MA 01501. INSURER D;Travelers Indemnity Company 25658-001 INSURER F; INSURERF; COVERAGES CERTIFICATE NUMBER:20287680 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. JzL INSRTYPE OF INSURANCE D II SU6 POLICYNUMBER POLICY EFF POLICY EXP yam LIMITS A GENERALLIAMILITY VTC20CD 977KS949-13 9/1./2013 9/1/2014 EACH OCCURRENCE IE_ 2,0 00 X COMMERCIAL GENERAL LIABILITY K0 TORENTF,p PRE al���(Ee oceuroncrl .R _ 3 0 0,p O Q CLAIMS-MADE�x OCCUR MED EXP(Anyoneperson) $ _LQ1 000 PERSONAL&ADV INJURY $ 21"A'000 GENERAL AGGREGATE $ 4,Q00,000 GEN'LAGGREGATFLIMITAPPUESPER; PRODUCTS-COMPIOPAGO v X000 000 POLICY PR0. LOC $ B AUTOMOBILE LIAM LITY VTJCAP 977K955A-7.3 /1/2013 9/1/2014 OMI3vEDent)SINGLELIMIT $ 2,000,000 X ANY AUTO BODILY INJURY(Per person) `R AI.I.OWNEll AS AUTOQ AUTOS BODILY INJURY(Peraccident) $ X HIREDAUTOS [X�A NON-OWNEDUTO8 eraccldent X Col o Des Coxl Deg $ C UMBRELLALIAB X OCCUR B38766140 /1/2013 9/1/2014 EACH OCCURRENCE L_5__0 00 000 EXCESS LIAe CLAIMS-MADE AGGREGATE $ $Q00,000 DED I }( IRETENTIONS 30,000 D WORKERS COMPENSATION VTRRUB 920SA105-13 9/1/207.3 9/1/207,4 X O AND EMPLOYERS'LIABILITY y N TORY,LJ ]0 ANY PROPRIETOWARTNFRIEXECUTIVEIN NIA VTC2XUB 8203.A71A-13 9/7,/2013 9/1/3014 E.L.EACH ACCIDENT s 1,000 000 OFFICFR/MEMBEREXCLUDED? L�JJ �Irs6deorylnNH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 T�Is KilldIrIUNUI UOft''RATIONSbelow F.,L,DIBEASH-POLICY LIMIT $ 1,000,Q00 DESCRIPTION OF OPERATIONS I I,00ATION31 VEHICLES(Attach Acord 101,Addltonel Remarks Schedula,If more specs It mqulrad) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Evidence of InmuzBence AUTHORIZED REPRESENTATIVE coll:4197604 Tpl:1694012 Cert:20287680 ©1988-2010ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD -7 Date.........lzqla............ T TOWN OF NORTH ANDOVER 'PERMIT FOR WIRING Thiscertifies that Ij............................................................................................. ................. o6r, has permission to performl.... ........................................................... wiring in the.building,of ....... ...............................................-.............. at ................I..........C--�- NL N rth Andover,Mass. ......................................................................... Lic.Nol-�>-1�5 Fee ..Zz................... ...............I ..... ...........Cd.........-..... ELECTRICAL CAL INSPEC70R Check# 4 117,39 60S - (A Z-1 I JI/ ` Commonwealth ®f Massachusetts Official Use Only Department ®f Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07) peaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MMC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: `7 " 2 Y /5 City or Town oh. 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) . " h�\\ )PWe Owner or Tenant 16U Telephone No. lk Owner's Address ` ! Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service (00 Amps o?40/ 0 Volts Overhead Undgrd❑ No.of Meters J New Service Amps / Volts Overhead❑ U rd ❑ No.of Meters Number of Feeders and Ampacity _ Location and Nature of Proposed Electrical Work: 6ce o1 4,ln p., p oij Completion of the followin—g table may be waived by the Inspector of Wires. 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- ❑ No.of Emergency Lighting rnd. grnd. 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 No.of Alerting Devices Tons No. of Waste Disposers Heat Pump Number .Tons KW_ No,of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal 0 .Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices 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 Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated'ValAe of Electric )York-:C f500 (When required by municipal policy.) Work to Start. } pections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C RAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of kBOND insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that suchge is in force,and has exhibited proof of same to the permit issuing office. NSURANCECHECK ONE: 1 ❑ OTHER ❑ (Specify:) I certify,cinder t1 pains and enol ' sof edury,that the information on this application is true and complete. FIRM NAM ` ' LIC.NO.: Licensee: Signatur LIC.NO.: (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: 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 a ent. 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 permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed 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 M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass X/ Failed 0 Re-Inspection"Required($.) ❑ Inspectors Comments: If / Inspectors Signature: Date: FINAL,INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: U4- li f Date: DEB WEINHOLD .'..TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations Uf 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ff Please Print Le ibl Name(Business/Organization/Individual): Address: VJ t -� City/State/Zip: a`�p� Phone#: 617) S� 9��� 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 ployees(full and/or part-time).* have hired the sub-contractors 2. m a sole proprietor or partner- listed on the attached sheet.t 7• E]Remodeling 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. I am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself. [No workers' comp, c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]r employees.[No workers' comp.insurance required.] 13.❑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 hie 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 thepolicy 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). Fqilure 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. Ido hereby ert under th pains andpenalties ofperjury that the information provide above is true and correct. f Simature: Date: Aa 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#: 1 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 ' e 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 m 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 s 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 of Massachusetts, � Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel,#61.7-727-4900 ext 406 or 1.-877rMASSAFB Revised 5-26-05 Fax#617-727-7749 wwwanass,gov/dia i { COMMOh11AfEALH OF MA1�,g,qCHS r ELE Q5CTRICIANF; ct� \s1 .�� A RCr�.�c�uRrsrY.n�,y,, a. ISS_UESFTHE ABOVE LICENSE Tc, o f ✓. ,1-�1' 1F Igt1.F` M l0LSI<E . y rIEII_t vr t;1A,�:tl�<lt� i i I I i f ,,�....,..,�..���......�.,�-�-.cam � 'MM©IV%FjANH 6iVA� SACHUSt a ,.... r L • ' C1ErfPlCIRi3��: ISSUESaTHE A80VE LICENSE 71, ' ,`,`• r ' tAtTF� ��1 tIULSLE . �y r r i Ti \' Date.... /..��............. r .} OF Vj0R'ry a; c� TOWN OF NORTH ANDOVER o PERMIT FOR WIRING B�cHus� This certifies that .: e�� /. has permission-to perform j .................. .. n. wiring in the building of.....:.........". ................................................................ at .... .. ..: ....................................................................................... orth Andover,Mass. Fee l'�.. .:Lic.No. �5�.. ..'...1.. ...... .............. .. . ............ ... Z..�+' ry - ` ,f 6 , ELECTRICAL INSPECTOR �� Check# _ 417 L/Z 7 Zo/ Commonwealth ®f Massachusetts Official Use Only Department of Fire Services Permit No. 7�z BOARD OF FIRE PREVENTION REGULATIONS [ROccupancy v.0] (leand ee lank)Checked w., (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 ININK OR TYPE ALL INFORMATION) Date: _Z- City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his orr`he intention to perform the electrical work described below. Location(Street&Number) 69 O`eW ��°�,& Owner or Tenant Telephone No. Owner's Address T Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Apropri to Box Purpose of Building Utility Authorization No. IS3V - Existing Service 700Amps /_'/2't0 Volts Overhead Y" Undgrd❑ No.of Meters New Service /D6 Amps ( Volts Overhead Undgrd ❑ No.of Meters J- Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ; r� � C Completion of the following table may be waived by the Inspector of Vires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- Elo.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 Initiatin Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No. of Waste Disposers Heat Pump Number Tons 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 Water KWNo.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: (When required by municipal policy.) Work to Start: I 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 " is equivalent. The the licensee provides proof of liability insurance including completed operation coverage or its substantial 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 fi pains andpgnalftes of perjury,that the information on this application is true and complete. FIRM N QS wk, .. LIC.NO.: Licensee: r,yjwt�- (9Signatur LTC.NO.: (If applicable,enter "exempt"in the license number line) Bus.Tel.No. I Address: 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 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 permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed 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 t 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 conceming 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($.) ❑ x Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: R Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: y Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL, S CTION: Pass 0 Failed '❑ Re-Inspection Required($.)❑ Inspect rs Com s: r Inspectors Signature: Date: DEB WEINHOLD TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Letziblv Name(Business/Organization/Individual : kle_ er+M- - Address: City/State/Zip: Phone#: 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 euaployees(full and/or part-time).* have hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet.# 7• ❑Remodeling 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 31:11 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.[:]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 a're 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. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. kao Policy#or Self-ins.Lic.M L Expiration Date: 1 Job Site Address:_(�J affA City/State/Zip: r A4 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 hereb ce ' unde h�pam �andpen�al perjury that the information provided above is true and correct. - r Signature: (� JDate: -kip, &%(3 Phone#: IC4 ` l �V- l`] 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#: 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." s 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 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 Massacl?usekts Department of l dustrial Accidents Office of Investigations 600 Washington Street Boston,MA.02111 Tei,#617-727-4100 ext 406 or 1-877:MASS.AFB Revised 5-26-05 Fax#617-727-7741 www-mass,govldia