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HomeMy WebLinkAboutMiscellaneous - 68 COMPASS POINT ROAD 4/30/2018 reB C�AY� Go, A � b� BUILDING FILE n Datel] �.l.. ye/% ........ 10 'C" i / Rrh�� TOWN OF NORTH ANDOVER O3?• `` •• OOH * PERMIT FOR PLUMBING gBACMU5E Vim// / p� � 4s� ( / /This certifies tha .........L... ��- -......................... ...... . ........................................................ haspermission to perform...,....�.,.,................................................................................. plumbing in the buildings of....�.e'b �l/PK' Y.0 at........ ......L.......... � .......... ' ................................ North Andover, Mass. /Mi 3� Z 7 . ?�"''' Fee............;.......Lic. No. .................... .............:................................................................. --5e ^' PLUMBING INSPECTOR, Check# UY /6-P MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY NORTH ANDOVER _ _ _ MA. DATE 1-5-15 PERMIT# JOBSITE ADDRESS 68 COMPASS POINT OWNER'S NAME TRUST CONSTRUCTION POWNER ADDRESS: 51 MT JOY DR TEWKSBURY MA TEL:1 5083209337 1 FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑■ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ I FIXUTRES Z FLOORS- Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 2 CROSS CONN DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIUSAND SYS DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYS DEDICATED WATER REUSE SYS DISHWASHER DRINKING FOUNTAIN FOOD WASTE GRINDER UNIT FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK 1 LAVATORY 1 3 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 2 URINAL WASHING MACHINE CONNECTION 1 V WATER HEATER ALL TYPES 1 WATER PIPING 1 SPIGOTS 2 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 have 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 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 applica' ar rue nd accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this appl' to ill b in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER NAME: MIKE BURKE LICENSE# 13127 SIGNATURE COMPANY NAME: I POWERHOUSE PLUMBING AND HEATING CORP ADDRESS: PO OX 896 CITY: PLAISTOW STATE: NH ; ZIP: 103865 FAX: 6033780040 TEL: 16033780020 CELL:119784909385w EMAIL: J.LAURENCIO@POWERHOUSEPLUMBING.COM MASTER❑N JOURNEYMAN 0 CORPORATION ❑Q # 2482__ PARTNERSHIP❑# LLC❑# __ GH PLUMBING INSPE TI N NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTN NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES Date.....1 ...CAA ................ o. °�NORTM,h TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 8s�c,�sE w ....... .. .. .. .This certifies that ` Sev. has permission for gas-installation .../.V...... ..........................................................:- ► in the buildings of..... -= .... .r)".6 t,c �_ r !................................. at.....l21�..........�...�... ......:,(`"../...�...................... North Andover,Mass. Fee../6h..-.. Lic. No)..312.1....... H1 �................................................ p GASINSPECTOR Check# i' 7 7 S MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I NORTH ANDOVER MA. DATE 1-5-15 PERMIT# JOBSITE ADDRESS _68 COMPASS POINT OWNER'S NAME I TRUST CONSTRUCTION GOWNER ADDRESS: 51 MT JOY DRIVE,TEWKSBURY MA TEL: 5083209337 FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑■ PRINT CLEARLY NEW: ■❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ FIXUTRES Z FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER • 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 have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY 0 OTHER TYPE 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 ❑ ENT [:1SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted(or entered)regarding this application are and ac ate t e best of my Knowledge and that all plumbing work and installations performed under the permit issued for this applicatio ' e in plian with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME: I MIKE BURKE _ LICENSE# 13127 IGNATURE COMPANY NAME: I POWERHOUSE PLUMBING AND HEATING CORP ADDRESS: I PO BOX Oft CITY: PLAISTOW STATE: NH ZIP: 03865 I FAX: 160337800470 TEL: [6033780020'_ CELL: 19784909385, EMAIL: J.LAURENCIO . OWERHOUSEPLUMBINGAND HEATING COM MASTER 0 JOURNEYMAN ❑ LP INSTALLER❑ CORPORATION A# 2482 PARTNERSHIP❑#=LLC❑#® ROUGH GAS INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No t e THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of Industrial Accidents 4 Office of Investigations • d I Congress Street,Suite 100 .t` Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): POWERHOUSE PLUMBING CORP Address:PO BOX 896 City/State/Zip:PLAISTOW, NH 03865 Phone#:6033780020 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 6 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6 K New construction 2.❑ 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 working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152,§1(4),and we have no/ employees. [No workers' 1 13.0 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:HARTFORD UNDERWRITERS INSURANCE COMP Policy#or Self-ins. Lic.#:04WECIT2480 Expiration Date:7-28-15 Job Site Address: 68 compass point City/State/Zip:North Andover ma Attach a copy of the workers' compensatio olicy declaration page(showing the policy number and expiration date). Failure to secure coverage as required un S ction 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 i riso ent, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day nst the ' lator. a advised that a copy of this statement may be forwarded to the Office of Investigations of the for in ante c erage verification. I do hereby cern u er tl: pains an penalties of perjury that the information provided above is true and correct. Signature: Date: 1-5-15 f Phone#: X033 0020 / Official use only. Do not fe 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#: mo 1TH;v MASSAc 1i sE1n s 7 �.. a • a � • • a • 15Su SaTg fALLOW!W It E_ 11 CE1-SED' AS Ai'J Y IA te'1r` . H1CliAE_L W SURKE ! M OMMOfiivllOS=H ©F 'AS"&t7sl?"[TS E • �' a a ; RIM w r BOARp OF 4kur q s AND GASF TTERS' Milt' s 1 V,t$30-1613 Rn R6 DATE '4C40RV CERTIFICATE OF LIABILITY INSURANCE1/5/2015 ) THIS CERTIFICATE IS ISSUED AS A 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. IMPOR ANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTNAMEACT Kathleen Miller, CISR, CPIW Insurance Solutions Corporation PHONE (603)382-4600 FAX Nol,(603)382-2034 60 Westville Rd EMAIL .kmiller@isc-insurance.com INSURERS AFFORDING COVERAGE NAIC# Plaistow NH 03865 INSURERAMerchants 23329 INSURED INSURERB:Hartford Underwriters Ins. Co. POWERHOUSE PLUMING & HEATING INSURERC: CORP INSURER D: PO BOX 896 INSURER E: PLAISTOW NH 03865-0896 INSURERF: COVERAGES CERTIFICATE NUMBER.-CL1472917730 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. INSR TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYW GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE T RENTED PREMISES Ea occurrence $ 500,000 A CLAIMS-MADE 5Z OCCUR BOPI065497 /1/2014 /1/2015 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 11000,000 A X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED CAPI058154 /1/2014 /1/2015 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident Medical payments $ 5,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE _ $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? Y N/A (Mandatory In NH) 04WECIT2480 /28/2014 /28/2015 E.L.DISEASE-EA EMPLOYE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION (978) 688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street Bldg 20 Ste 2035 AUTHORIZED REPRESENTATIVE North Andover, MA 01845 L Keith Maglia/KRM -7\ ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INSn25nninn5tm Tho annPi i nama and Innn era ranieforarl marke of anr1R11 Date.... . ........1... ................. OF r►ORTh,� TOWN OF NORTH ANDOVER '• 9 PERMIT FOR WIRING * %V . . s$,CHO c, -t--r-� , �o A L1 Pas Thiscertifies that .. ...!.............................................................................................................. has permission to perform , Q: L -x- ......................................................................... wiring in the building of.....,.. .� .. ............................................................. at . , 8 s� N h Andover,Mass. Fee. .S?...............Lic.No. ................. -It. .. . . ELECTRICALNSPECTOR Check# ,, �4— Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked ,M BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of: 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) (AR cb M Pa- v0 Owner or Tenant ru' Co r, o Q. Telephone No. Owner's Address cog, 3� Is this permit in conjunction with a building permit? Yes F] No ❑ (Check Appropriate Box) ! ��R Utility Authorization No. Purpose of Building •�Vw 1 - Existing Service Amps / Volts Overhead❑ Undgrd No.of Meters A New Service Amps 11-P / POVolts 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. 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 Above ❑ In- ❑ .o Emergency Lighting rnd. rnd. Baotter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones ky No.of Switches No.of Gas Burners No.of Detection and Initiatin Devices No.of Ranges No.of Air Cond. Total ons No.of Alerting Devices T No.of Waste Disposers Heat Pump Number Tons K 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 KW No.of No.of Data Wirin : Heaters Signs Ballasts No.of Dgevices 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 97res. Estimated Value of ectr calork: 3" JIU�-0) (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO RA E: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provi -,t proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov rage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: 119SURANCE X1 BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and pe lties o perjury,that the information on this application is true and complete. FIItM NAME: . ( Co C LIC.NO.: Licensee: .(tel Signature LIC.NO.: 2 (Ifapplicable,enter "exempt"in the license number line) Bus.Tel.No.• • fG1`3 Address: Alt.Tel.No. r' `— LO� *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.No.� OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage n ally 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 �. 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. F 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?' Failed Re-Inspection Required($.) ❑ Inspectors Comments: r Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass R Failed❑' Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Sign re: Date: ROUGH INECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: — FINAL INSPE ION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: 7 —/0 DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com i v' The Commonwealth of Massachusetts • I F Department of fndustrialAccidents I Congress Street,Suite 100 y Boston,MA 02114-2017 www mass.gov/dia Workers"Compensation insurance Affidavit:Builders/Contractors/Electricians/)'luxnbers. TO BE FILED WITH THE PERMITTING AUTHORITY. please Print Leably A licant Information cg PJ Name(Business/Orgabization/Individual): Address: City/State/Zip: Phone#: —96 33 Are you an employer?Check the appropriate box: Type of project(required): em to es fiill and/or part-time).* 7. ❑Nevv d6nstrd6tion 1.[]I am a employer with P ye 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. kemo deling any capacity.[No workers'comp.insurance required] 9. ❑Demolition 3.Q 1 am a homeowner doing all work myself.[No workers'comp.insurance required]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12�Q Plumbing repairs or additions 5.0 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13•.0 Ro6f repairs These sub-contractors have employees and have workers'comp.insurance.t 14.rl Other 6.Q We are a corporatiori and its.officers have exercised their right of exemption per MGL c. 152,§1(4),and We have no employees.[No workers'comp.insurance required.] *Arty applicant that check's box#1 must also fill out the section below showing their workers'compensation policy information. homeowners who submit•this aMS avit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. Contractors that check this box must attache additional sheet showing the name of the sub-contractors and state whether or not(hose entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. X am an employer that is providing workers'compensation insurance for my employees. Below,is the policy and job site information. �v�1`�^ Insurance Company Name: _ U P 6 ' 00 \ (� ���" ExpirationDate' I Ig Policy#or Self-ins.Liic.#: y q Job Site Address: �t - City/State/Zip: C�MQ�s� pk a copy of the workers' compensation policy declaration page(showing the policy numb x and expiration date). Attach Failure teach to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 penalties in the form of a S'T'OP WORK ORDER and a fine of up to $250.00 a and/or one-year imprisonment,as well as civil be forwarded to the Office of Investigations of the DIA for insurance day against the violator.A copy of this statement may coverage verification. X do hereby cert under t pains and penalties of p yury that the information provided above s true nd.correct. . Date: � \ Signature: Phone if: 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 Phone#• Contact Person: r � r% 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 enferprise,and including the legal representatives of a deceased employer,or the receivef'or trustee 6f 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 b6 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 certificates)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 burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia 4r M FSP : f�MMONWEALTH OF MASSACHUSETTS BOAR OF j EJ;ECTF?'I C i SNS; r €:`€>' ISSU�,5. .T:HE FOLLOW i .0.;`t'(CENSE:;„ AS A REG tOURNEYMAN LECTI 1,.1 N: MICHAEL A FAR INQ ui i 23 H ORCfARD<:AVE W HaVERHI�L MA o1830 438 G t 2955 , 0773.x. 1 69600 1 . ., . Page I of Print View 53-179-113 1381 ALL PRO'S ELECTRIC CORPORATION - 2 MARTENS ST _ k WILMINGTON.MA 01887 `rte . Li in Aw J r J ___--- (ftastan Bank 6 uw t�- g CO 30 09fi ll0600 76 7040il• & 3131 r ✓� q Date 1 . TOWN OF NORTH ANDOVER PERMIT FOR WIRING M «y r r " >s s —7 , t �• .. CeI�3l ��� .Z4 rorm ...6....... .. �. t ............ .... ... North Andover, Mass. ........ , ........... E[ECI RiCAL 1NSP ....pR~.............. ... ' Cf 13H7 OX- /3117 �'1 7�'�v�. ✓Le. r S� �. c•�'"Ye�t S '� 7oZ. C.`�c,.vi �� i I DateQ�..R. .�..(. :.............. OF r►ORTI.��h TOWN OF NORTH ANDOVER PERMIT FOR WIRING t SSACHUS� This certifies that ..................: ? '- .................'* - q�........................... has permission to perform .. .....ram..e... ........ al-r5 ............... wiring in the building of......6 ...... ................................................................... �'�/ .. N rth Andover,Mas . at ..�! .�. .... -.............................. ...� .. ................. .. hee..f` .. ......Lic.No. .... ....... . ............ ..... LECTRICAL I SPC R Check# Commonwealth of Massachusetts Official Use Only Permit No. � ?J Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00/ (PLEASE PRINT IN MK OR TYPE ALL INFORMATION) Date: a`-1 O- l,s City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work descri d below. Location(Street&Number) O lY) lb. I V(,/g//7 Owner or Tenant �i(t,`,S7rlTYt.�-G�lTelephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building A&t- Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps 2W Volts Overhead❑ Undgrd No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: /Ueg-,-) (-7t Z 3cxC -S�a can z Q Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans '2,, No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above In- o.o Emergency Lighting rnd. ❑ rnd. ❑ 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 f 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 ❑ Other Connection No.of Dryers l Heating Appliances KW Security Systems:* No.of Devices or Equivalent No. f 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 Value of Electrical WOJ�: f'2 (When required by municipal policy.) Work to Start: el— /©-/tj 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:) A'certify,under thepains and nadties ofp jury,that the information on this application is true and complete. _ FIRM NAME: . LIC.NO.: 17 Licensee: Ppjp�- j2e& Signature LIC.NO.: Q q r (If applicabl,enter "exempt"in the license number line.) Bus.Tel.No.• 33 Address: a 1 '7'Y-JS =Tt(��O Q5D� 7i 5 Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Publi afety"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 electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the y 1. 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($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: ' UL Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass[a Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUG PECTION: Pass 2)( Failed 1fl Re-Inspection Required($.) ❑ Inspectors ments: G�y Inspectors Signa re: Date: FINAL INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhoid@townofinerrimac.com _ The Commonwealth of lt2assachasetts , - Department oflndicstrial AccWnts Office oflnvestigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers'Compensation Yourance Affidavit:Buuders/Cont°actors/FIecfriczansMli iapers Applicant:Tnformatiion Please Print Le�libXy Name(Busincssiorganization&dividual): Address: - O 1 City/State/Zip: Phone#: Axe y an employer?Check the appropriate box: Type of project(required): 1. I am.a employer with '--7 4• ❑ I am a general contractor and I 6, (1 New construction employees(full and/or part time)* have nedthe sub-contractors 2.El am a sole proprietor or partner listed on the attached sheet. 7• [1 Remodeling ship and1ave no.employees These sub-contractors have 8. ❑Demolition working forme in any capacity. workers'comp.insurance, 9. ❑Buil " g addition [No workers'comp.insurance 5. ElWe are a corporation and its required.] officers have exerelsed.theix 10, ectrical repairs or additions 3.❑ I am a honeowner doing all work right of exemption per MGL 11.[]Plumbing.repairs or additions myself.[No workers'comp. c.152,§1(4),andwehaveno 12.QRoofrepairs insuraucexequired.]i employees.[No workers' 13.0 Other comp.insurance required.] xAny applicantihat checks box#I must also fill outthe section below showingtheir workers'compensationpoHey information. 'Homeownerswho submitihisaffidavitindicatingtheyRdping allworkand thenhire outside contractors must submit anew affidavit indicaffig such. tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that isproviding workers'compensation insurance formy employees. Below is thepoliey and job site information. Insurance Company Name:_ Policy#or Self ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach,a copy oldie workers'compensation.palley declaration page(showing the policy number and expiration date). failure to secure coverage as requiredunder Section 25A ofMGL c. 152 can lead to the imposition,of criminal penalties of a firo e up to$1,50 0.00 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 liereby cert&under the pains andpenalties ofperjury that the information provided above is true and correct. - Signature: Date: Phone#• Official use oitly. .Do not write in 01s area,to be completed by city or town offciaZ City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Numbing 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 of hire,• express or implied,oral or written." An employee is defined as"an individual,partnership,association,corporation or other legal entity,or anytwo or more of theforegoing engaged in a j oint enterprise,and including the legal representatives of a-deceased employer,or the receiver or ttiistee'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 chapterhave b con presented to,the contracting authority.." Applicants Please fill out the workers'compensailon affidavit completely,by checking the boxes that apply to your situation and,if necessary ,supply sub-confractor(s)name(s),address(es)andphonenumber(s)alongwiththeir certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members orpartners,arenotrequiredto carry workers'compensation insurance. If an LLC orLLP doeshave / employees,a policy is required. B e advised thattliis affidavit maybe submitted to the Department of Industrial ` Accidents for confirmation of insurance coverage. Also be sure to sign and date the a1fdavit. 'II:'he 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 yrorkers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on tho appropriate line. City or Town Officials Please be sure thatthe 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-sue to fill in the permit/license number whichwill 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(ifnecessary)and under"rib Site Address"the applicant shouldwrite"all locations in (city or tov ):'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. Anew affidavit must be filled out each. year.Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license orpermit to burn leaves etc)said person is NOT required to complete this affidavit. The Office of Investigations would Moto thank you in advance for your cooperation and should you have any questions, please do nothesitate to give us a call. The Department's address,telephone and fax number: `�'he�o: ox���aX�.z o�.1�1'assa..ehvsPtts •Department of IndusWal.Acoidents Q£Aee of fAvestigatim 60 WaMraa ee Boston,NA 4.21.X x Tel#61.7-7-27,4900 e 406 or-1-8,77:1 S.FE Devised 5-26-05 Fax 0 617-727-7749 �ax�ass.g���clia .