HomeMy WebLinkAboutMiscellaneous - 672 MASSACHUSETTS AVENUE 4/30/2018 672 MASSACHUSETTS AVENUE
2101059.0.0005-0000.0
Date... ........
04 VLOR
0
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
TIC
S CHUS
Et
This certifies that ....... ...............................................
has permission to perform .... .............
wiring in the building of.......
• at....... ✓ ...... .................... North Andover,Mass.
Fee Lic.No r-Ok.1 ...........
ELE -�R A
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Check
9'1 '15
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked J _
[Rev. 1/07] (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance.with the Massachusetts Electrical Code(ME ),52 CMR 12.00
(PLEASE PRINT WINK OR TYPE ALL INFORMATIOA9 Date: Q
City or Town of: NORTH ANDOVER
To the Inspector f Wires:
By this application the undersigned gives notal of his or h—
er.mtention to perf rm the electrical work described below.
Location(Street&Number) � l / .
Owner or Tenant T-L o
bN �-� � A Tele
Owner's Address one No.
Is this permit in conjunction with a building permit? yes
Purpose of Building A/6( � I '--INO ❑ (Chec Appropriate Boa)
W i No
orization No.7L`� a
Existing Service `U' Amps / 0� �J Volts Overhead
a� /' dgrd❑ No.of Meters
New Service Amps o�l)�Volts Overhead Und rd
Number of Feeders and.Ampacity g ❑ No.of Meters
Location and attire of Proposed Electrical Work: NG / d I liL
Completion of the ollowin table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil.-Sus No.of Total .
p.(Paddle)Fans Transformers KVA
No.of Luminaire Outlets _ No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above In- o.o mergency
d• � d• � Batte Units g
--, No.of Receptacle Outlets No.of Oil Burners
' FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
No.of Ranges No.of Air Cond. Total Initiating Devices
Tons No.of Alerting Devices
No.of Waste Disposers Heat PSP Number ons KW
P Totalo.of Self-Containe
Detection/Ale!*ng Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal
Connection ❑ Other
No.of Dryers Heating Appliances KW Security Systems.*
No.of Water KW No.of No.of , No.of Devices or Equivalent
Heaters Si s Ballasts ata Wiring:
No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
� OTHER:
No.of Devices or E uing: it
Attach additional detail if desired, oras required by the Inspector of Wires.
Estimated Value of Electrical Work:
g (When required by municipal policy.)
Work to Start
INSURANCE CInspections to be requested in accordance with MEC Rule 10,and upon completion.
OVERAGE: 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, P �'�)
under the pains penalties erju7, that the information on this application is true and completg
FIRM NAME.
..,
Licensee: � ' � Signature LIC.NO
(If applicable, enter"exempt"in the license number 'ne. LIC.NO.:
Address: __. i,( / clsBus.Tel.No.:
*Per M.G.L c 147 s.5 61 secun work re D Alt.Tel.No.: j
' ty requires q 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
Signature Telephone No. PERMIT FEE: $'
r
The Commonwealth of Massachusetts
.� Department of Industrial Accidents
Office ofinvestigations
600 Washington Street
,Boston, AlA-02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Naive (Business/Organization/Individual): l ~
G
Address: (i(Jt] LU�� vQ
City/State/Zip: J))J tL ,AfT/]/�!� �/7Sl,�Phone#:
Are you an employer? Check the appropriate bog: Type of project(required):
1.❑ a employer with 4. ElI am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2. I 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 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 workers' comp. c. 152, §1(4), and we have no 12.❑Roof repairs
insurance required.] t ..employees. [No workers'
comp. insurance required.]. 13.❑ Other
* :.y applicant that checks #; alsc 811 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.
tContractors 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. Lie.#: 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).
v 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 weU as civil penalties in the form of a STOP WORK ORDER and a fine .
1 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 cer ithe pains nd pgnaliks of perjury that the information provided abo a is ue and correct
Signafore: Date: i7
Phone#:
[[60
icial use only. Do not write in this area,to be completed by city or town official
y or Town: Permit/License#
ing Authority(circle one):
oard of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
thertact Person: Phone `:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers toprovide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a,deceased employer,or the .
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs.persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability.Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or'License is being requested; not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not relaxed 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.
(�fice of Investigations
600 Washmgton.Street
Boston,ASIA.0.2111
Tel. # 617-7274.900 ext 4:06 or 1-877-MASSAFE
Revised 5-26-05
Fax 4 617-72.7-7749
",w-A,.mass.gov/dia
NO
Town of over
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No. 2ZZZ-00
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C, 0LAKE dove, Hass., 2
COC MIC MEW1 M a
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�A0RATED
w BOARD OF HEALTH
i
PERMIT T 71'
Food/Kitchen
' r Septic System
. �J.� �. G svG�Q � BUILDING INSPECTOR
THIS CERTIFIES THAT............ /�-�. L. .. ...( .........
Foundation
has permission to erect........................................ buildings on!.....��.. ... . .� ... �' g I
"� Rou h
� pp - :�ISCJi�,y cam.
to be occupied as.............c �%1.... a .��r��' � i...... '� ". Chimney
provided that the person accepting this permit sham every respect conform to the tefms of they ;�p�catlon on file in a ,i� o
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, AReration�am Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. g %�G�`f6
r 1 S �Qq>
PERMIT EXPIRES IN 6 MONTHS
UNLESS CONSTRUCTION STARTS ' EL ICAL INSPECTO
Service Qs4E_--�.�2 c r'
I3'JtLDING YNSPECTOR
Occupancy Permit Required to Occupy Building GAS INPECTOR
Display Conspicuous Place on the Premises �fj Not Remove �b
P Y in a Cons P
No Lathing or Dry Wall To Be DopF) FIRE DEPARTM
Until Inspected and Approved by the Buildispector. Burner
Street No.
Sz11 y �
SEE REVERSE SIDE3 smoke Det. s-ice_ 10
7442 Date. �.1.�!k v........
,FORTH
3? TOWN OF NORTH ANDOVER
a PERMIT FOR GAS INSTALLATION
SS CH
V
This certifies that . . . . .`. . . . . . . .
has permission for gas installation . I/�c��—
t/��. . . . . .
in the buildings of . !L�:w.� ... .`'.. . . . . . . . . . . . .
at . f_r.7�. . . .!��r�. . U f . . . . . . ., North Andover, Mass.
Fee.',;,).�.�"E? . Lic. No.. &0 4: . 4AII .
GAS IN EC OR
Check#��
GAB Robins North America, Inc.
21 High St.
North Andover, MA 01845
Date 12/05/2011
Building Commissioner/Inspector of Buildings
Town Offices
NORTH ANDOVER, MA 01845
Board of Health/Board of Selectmen
RflI�I1S
G.B Mimi Noith8mriz2,1tr.
NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 313
Claim has been made involving loss, damage or destruction of the property captioned below, which may either exceed_
$1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under
Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and
include a reference to the captioned insured, location, policy number, date of loss, and GAB Robins file number.
Insured: JAYNE LANNAN
Property Address:
672 MASSACHUSETTS AVE
NORTH ANDOVER, MA01845
Policy No. 2641884
Loss of DURING HURRICANE IRENE,WIND BLEW DOWN TREES IN YARD AND Date/Yr.
DAMAGED FENCE
DATE OF LOSS: 08/25/2011
GAB Robins File No. 548657983626
FRANK EDWARDS
(Signature)
Title: Adjuster
On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by
first class mail.
(Signature and date)
Form PR0645(2/78)
MASSACHliSEM LTMEM APNJCATON FOR PERNIrr TO DO GAS FfITING
(Type or print) Date
NORTH ANDOVER,MASSACHUSETTS
Building Locations 7 Du `P' Permit#
Amount$
Owner's Name
NewRenovation ❑ Replacement ❑ {Plans Submitted
4cn r� 0 tD
O
Z Z O F, W
0 O y`7' O 7� F
O CAA
91
t7 Ch
C H 4 C7 O z Ow :10.
r, a F r�
SUB -BASEM ENT
BASEir1 ENT
1ST. FLOOR
2ND . FLOOR
n 3RD. FLOOR
4T II . FLOOR
5TH . FLOOR
6TH. FLOOR
7TH . YL00R
8TH . FLOOR
(Print or type) --1— Ch�ec c one: Certificate Installing Company
Name ��- 4117-P J I I Corp
Address ��� 13 d u L❑ Partner..
kIT
Business e ephone 7 1, �� �. D-F-irm/Co.
Mame of Licensed Plumber or Gas Fitter `3d 12
INSURANCE COVERAGE Check one•
I have a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checked yg�,please in ate the type coverage by checking the appropriate-box.
Liability insurance policy Other type of indemnity Bond 13
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass.General Laws,and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 0 Agent
hereby certify that all of the details and information I have Submitted(or entered)in above application are true and accurate to the-
hest of m} knowledge and that all plumbingwork and ins rrl ; ions p nrmod under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massae is I S Ste Gas Cndc.� Chapter 1 ?of the Ge ral Laws.
B„. Signature of Lie ed Plumber Or Gas Fitter
TitlePhtmbcr
Cityr'To vn 0 Gas Fitter tcensr;i um err
I I aMaster
APPROVED(OFFICE USE ONLY) 0 Journeyman
976e
Date..................................
NORTiy
" TOWN OF NORTH ANDOVER{
p PERMIT FOR WIRING
ACMU
This certifies that ........ .. :..... !'r`. ../.............................................
has permission to perform ..... ✓ �
........" ..................
................
wiring in the building of.........� . .. G ......... .! r , :...........
.
at.lS�. .......... 1� ��✓:............�....................... rth Andover,Mass.
Fee. . .....:A Lic.No!7..d1rl.33...............
y� ELECTRICAL INSPECTOR
Check # I
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c. 143,§3L,the ;P
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_brt thp-Tnspxctor-of Wires abandoned_and_invalid,if_he—__. ._
or she has determined that the authorized-workhas 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 pen-nit 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;nd 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.
rle 8—Permit/Date Closed: l ***Note:Reap �
Reapply for new permi
rmit Extension Act—Permit/Date Closed: -- \\
Common"N" Of Massachu-sem Official Use t?nty
Department of Fire Services Permit No. /? w/ 7
BOARD OF FIRE PREVENTION REGULATIONS Rev-
1/0nc y and Fee Checked
Rev. ra71 tedde b,artk --
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL W
All work to be px•rformed in accordance with the Massttchus-is Elac:trie al C+ade(MEC}.527 CMR 12.(X)WORK
(1'1 EASE'f RENT'IN INK OR T'I'NE ALG INFORMATION} Date:
City err Town of: NORTH ANDOVER �e
By this applicatton the undersigned gives notice of h
Location(Street& Number) is or her intention to perform thJtelePc electrical work dtescribed below.
---17_� .ate 'L
Owner or`l�cnant ^
Owner's Address Telephone No.
t -----—
Is this permit in conjunction: with a building permit? Yes
Purpose of Building i No ❑ (Check Appropriate Sox)
Utility Authorization No.
Existing Service 2 ps f 7�i / 2 v Volts Overhead �'Lnd
grd❑ No.of Meters
Ne Service Amps i Notts Overhead� Un
Number of Feeders and Ampacity �d❑ No. of Meters
Location and Mature of Proposed Electrical Work:
L�tLl x&a�t
+ 1 Com letiorr-i the o!!aa in ta'",mu oe waived b} the!ns eetor o if ire
r No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans o.o
ora
No.of Luminaire Outlets Transformers KVA
No.of Hot Tubs Generators KVA
No.of luminaires ; Swimming Pool aVe [] fr
o.o mergency .tg Ing
No.of Receptacle Outlets rud. d. ❑ Batte Units
No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners o•o etectton tin
No.of MangesInitiatin Devices
No,of Air Cond. ora
Tons No.of Alerting Devices
No.of Waste Disposers eat ump om er ons o.o e - ontatne
Totals; DetectiontAlertin Devices
No.of Dishwashers Space/Area Heating KW Local p
umct s ❑ Other
No.of Dryers ❑ Connection
Heating Appliances KW ecurity,ystems,.Ir
NO.it, aver K W o.o o.o No.ofevices or E trivalent
• !!eaters Signs Ballasts Data Wiring:
No. Hydromassage BathtubsTele
No.of Devices or Equivalent
No.of Motors Total NP a ecommunications tring:
OTHER. No.of Devices or E uivalent
•attach additional de:tait iI destred, or as required by the last,cctor of lf'ire�
Estimated Value Oft-lectrical Work.
(When required by municipal policy.)
Work to titan: 1/-Z5 —/(/ Inspections to be requested in accordance with MEC Rule 10,and upon
completiorL
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance ofelectricawork 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 proofot•'same to the permit issuing otlice.
CHECK ONE: INSURANCE OND
I c•erti ❑ OTHER ❑ (Specify:).
fy,under the pains and penalties of perjury,that the information on this NAME; is true and te,mplete.
FIRM NAE: �j. '
Licensee-� _
,r / Signature
11 rlt,lrr rhlr. <.rt r "e irrupt f to the!ie rase a,+mher line.) LIC. NO.:
1dd.reSS: �? C 11. i�60.:`f� 7- ? G
�• Bus.
a �—•�
c. 147.,• 5 -t,1,security work require.Ih partrn of Public Safet S" License: Alt.'Tel. No.:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does rt(w have the liability insurance coverage normally by law. By my signature below, I hereby waive this requirement l am the(cheek one)[}nuner
()caner/Agent owner's agent.
Signature _ _ Telephone No._. PERMIT FEE. $
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