HomeMy WebLinkAboutMiscellaneous - 68 BOSTON HILL ROAD 4/30/2018 f 68 BOSTON HILL ROAD \
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3r°•�;�`"-;'�•"°o� TOWN OF NORTH ANDOVER
o PERMIT FOR WIRING
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This certifies that .....................................' .S'i'► • ..( ���t � `
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has permission to perform ... ........!t! r!* !.z..t
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wiring in the building of.........�.K."........W �/'`.f.............................
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INSPECTOR
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\ Commonwealth Of Massachusetts91 Official Use only
Hirma
Department of Fire Services Permit No. _��.�
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
Rev. 11071 l�Ve blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachu wits Electrical G0de(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION} Date:
City or Town �f: U NORTH AND2� —
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To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the el trical work described below.
Location(Street& Number)
Owner or Tenant •��`t
owner's Address Telephone No.
ri.
Is this permit in conjunction with a building permit? Yes
Purpose of Building ElNo (Check Appropriate Box)
— �' 7y�-c ��''''�y Utility Authorization No.�
Existing Service6 6 Amps 1 Volts
---�_._ Overhead ❑ Undgrd❑ No.of Meters
New— see Z—�/v Amps 12 0 r1 �/G Volts Overhead
Number of Feeders and AmpacityUndgrd ❑ No.of Meters
Location and Nature of Proposed Electrical Work:
Gv r�
Com lotion o the ollow�in table ma be waived b the Inspector o Wire.
No.o€Recessed Luminaires No,of Ceit.-Susp.(Paddle)Fans °•o ota
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs
Generators KVA
rad. rnd
No.of Luminaires Swimming Pool Above ❑ a- . � Batte Units o.o mergency Ig ng
No.of Receptacle Outlets No.of Oil Burners
FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.o e an
No-of RangesInitiatin Devices
No.of Air Cond. ora
Tons No.of Alerting Devices
No.of Waste Disposers eat ump um er ons
Totals• o,o e - ontarne
No.of Dishwashers Detection/Alertin Devices
Space/Area Heating KW Local❑ unictpa
No.of Drye Connection El Other
y Heating AppliancesKWunty ystems:
No.No.o ater No.of Devices or Equivalent
Heaters KW o o a
' Si ns Ballasts Data Wiring:
No. Hydromassa a Bathtubs No.of Devices or Equivalent
g No.of Motors Total HP a ecommuntcahons trtng:
OTHER No.of Devices or Equivalent
Attach adattlonal detail if desired.or as required by the Inspector of Wirr.1
Estimated Value of i {ectrical Work:
Work to Starr: a — v (When required by municipal policy.)
` / Inspections to be requested in accordance with MEC Rule 10,and upon completion.
1NSt1RANCE 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 forte,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE OND ❑ OTHER
I certify,under the pains and penalties u ❑ (Specify:)
P f perjury,that the information on this application ry true and completes
FIRM NAME: /J � ,�
Licensee: LIC. NO.: �q y j
�tJ r�l�/i(icrh/r.���•r exempt/irt the lic.ense�rmhCrl� ine} Signature .:r -- LIC. NO.:/I-?? 3 3
Address: 's,71111,1_1
Ic Bus.
*Per M.G.I.c. 147,,s, 5 -6f,security work requires Departm of Public Sa�ety"S" License: Aft.Loc.l.No.:
OWNER'S INSURANCE WAIVER: f am aware that the Licensee sloes nut have the liability insurance coverage normally
required by law. fly my signature below, t hereby waive this requirement. 1 am the(check one)[]owner owner's agent.
ly
Owner/Agent
Signature
Telephone No.
P PERMIT FEE. S < 5
Date/a
01 NORT: ti TOWN OF NORTH ANDOVER
..•° ,
- PERMIT FOR PLUMBING
I y �Y,•O••r�°•A�<y
r SSACNUS� /
' This certifies that . . . . . . . . . . .
has permission to perform-An- ��.- . . . . . . . . . . . . . . . . . .
I plumbing in the buildings of .. . . . . . . . . . . . . . . . . . . . .
atl� -� ^ - -•^- --''. ��t!. . . ,,North Andover, Mass.
. . . . . . . . . . . . :-. . . . . . . .
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Feer.�. . . . .Lic. No/.. . .�, !. . . . /. .,./. .--=�= . .�'�--. . . . . . . . . . . . . .
1 PLUG INSPECTOR
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,MASSACHUSETTS
Date -64m o
Building Location ?; (3os--k6N Pemlit#
Owner U GE W r-- SIJ 1 L-Lt 5 Amount 6 5?-
New
?New Renovation Replacement Plans Submitted Yes No
FIXTURES
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7IH IIDQt
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(Print or t3W) _ll ,�1 Check one: Certificate
k&zIliug Company Name �y Iy R�� �lf, ��-l� ,�6— ❑ Corp.
Address ?, (-) rL �T W1
Partner.
Business Telep — "� `-�t to [J"Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate—thethe- of insurance coverage by checking the appropriate box:
Liability insurance policy E Other type of indemnity 11 Bond
I� ❑
Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner Agent
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and installa •ons performed under permit Issued for this application will be m
compliance with all pertinent provisions of the Massachus tate Plum Code acid Chapter 142 of the General Laws.
' Ianatrrre o mcens um t/�✓y��
Title
Type of PIumbing License
.�.�
City/Town rcense umt�„or Master ❑ Journeyman
APPROVED(oma usE oNL
r
�l
.. _..
The Commonwealth of Massachusetts
Department of industrial Accidents
Office of investigations
600 Washington Street
Boston, MA 02111
www.mass govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): l� N'Ry,/ W�� �1 /�,1cy
Address:
City/State/Zip: N( 27 RPhone#:
Are you an employer?Check the appropriate box:
Type of project(required):
L ZI
a employer with 4. ❑ I am a general contractor and I
loyees(full and/or part-time).* have hired the sub-contractors6 ❑New construction
2. a sole proprietor or partner- listed on the attached sheet. 1 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance.
[No workers' comp. insurance 5• ❑ We are a corporation and its 9' F-1 Building addition
required.] officers have exercised their 10.0 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 12,0 Roof repairs
insurance required.] t employees. [No workers'
comp.insurance required.] 13.❑ Other
."may applicant that checks boy;41 must also fill out the sectio--below showi g their world'compensation p0hey in
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.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).
1
' 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 unfer the pains andpenaltre' J of perjury that the information provided above is true 4d correct
Si ature: / >
A p- Ko
o
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#:
A
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
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 permittlicense 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 r
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 Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 4406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05
www.mass..gov/dna