HomeMy WebLinkAboutMiscellaneous - 69 UNION STREET 4/30/2018ti
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Date ...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
has permission to ..... V .... k ... A .....
wiring in the building of...... CY.j
atI,,— -05
............................................................... ......................... . North Andover, Mass.
Fee.. ........ Lic. No. 2--eS21
................. ....................................................................................
ELECTRICAL INSPECTOR
Check #
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 1611 1
Occupancy and Fee. Checked
[Rev. 1/071 (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 WORMATION) Date: AZD
City or Town of: NORTH ANDOVER To the In pector of irlr-es:
By this application the undersigned gives notice of his orher intention to perform the electrical work described below.
Location (Street & Number) /0 00/0/L
Owner or Tenant
Owner'sAddress 3 `� ti �� f fi l (1W a
Is this permit in conjunction with builping Irrint . Yes ❑ No
Telephone No.
(Check Appropriate Box)
t Purpose of Building �P 61 M& !RUtili uthorization No.
- Existing Service Amps / olts Overhead F Undgrd ❑
,.� New Service Amps / Volts Overhead ❑ Undgrd ❑
Number of Feeders and Ampacity
rQ Location and Nature of Proposed Electrical Work:
Cv— V
No. of Meters
No. of Meters
Completion ofthe followinz table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Cel 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- ❑
rnd. grnd.
o. of Emergency Lighting
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
Initiating Devices
No. of Ranges
g
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Dis posers
p
Heat Pump
Totals:
Number
.................
Tons
KW
.......................
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
p g
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
SecurityNo. ys vim
: or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
,A 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: 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 i urance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverXe is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
X certify, under the pains and penalties ofperjury, tha the info ion on this application is true and complete.
FHM NAME: - f 0. LIC. NO.:
Licensee: � M&A X cow Signatur 1p LTC. NO.: �'
(If applicable, enter "exempt" in the license number line.) Bus. Tel. No.:
Address: Alt. Tel. No.: Q V
*Per M.G.L c. 147, s. 57-61, security work requires Departme 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 tq
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 r•
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:
Trenrh4aMteetim
Pass
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 ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPEC ON:
Pass 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date: �� L
FINAL INSPCTION:
Pass
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
44 4
Inspectors Signature:
Date: 7
DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com
M
The Commonwealth of -1V11"assachusetts
Department of.industrial Accidents
M r I Congress Street, Suite 100
_ d
Boston, MA 02114-2017
- -
www mass.gov/dia
OSM Syv
Workers' Compensation Insurance Affidavit: Builders/Contxactors/Electricians/Plum ers.
TO BE TILED WITH THE PERMLTT'NG AUTSORITY. PA.+ 1
Dame (Business/Organ iz//a��tiou/lndividual): j�
Address:
City/State/Zip:
Phone #:
Are you an employer? Check the appropriate bo
employees (frill and/or part-time)."'
1..❑ I a employer with
2, am a sole proprietor or partnership and have no employees Working for me in
city ran workers' comp. insurance required.]
any capa
3.0 I am a homeowner doing all work myself [No workers' comp. insurance required.] t
4. r]I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no 'employees.
5.❑I am a general contractor, and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance .$
6, ❑ We are a corporation and its. officers have exercised their right of exemption per MGL c.
1 4 and we have no employdes. [No workers' comp. insurance required.]
Type of project (required):
7. ❑ New'constxiiction
8. [] kemodel,19
9. ❑ Demoli ion
10 ❑ Bu' mg addition
11. lec4ical repairs or additigAs
12 Qplumbing repairs or additions
13-. j Roof repairs
14.n Other
*Any applicant that checks, box #1 must also fill out the section below showing their workers' compensation policy information. tin o
? Homeowners who submit•this affida It cued an additional they are doing the name of theall work andthen hire contractotside rs and state wheth rsmust submit anew or not thoseentities have
$Contractors that checktbis box must att
employees. If the sub contractors have employees, they must provide their workers' comp. policy number.
loyees. Below is the policy and job site
X am an employer that is providing workers' compensation insurance for my emp
information.
Insurance Company Name:
Expiration Date'
Policy # or Self -ins. Lic.11 (�
q ��t� 'ice City/State/Zip: ieX J
Job Site Address: 1
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
0.00
Failure to secure coverage as required under MGL
nalties2inthe form ofaSTOP WORK ORDER Iand fine f up to $2050.00 a
and/or one-year' imprisonment, as well as civil pe
be forwarded to the Office of Investigations of the DIA for insurance
day against the violator. A copy of this statement may
� under thepains andpenalties ofperjury that the information provt e
aav vets
-udo hereby c
14.
Official use only. Do not write in this area, to be completed by city or town offrcial.
Permit/License #
City or Town'
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:
4*
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
applicatit 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
Pleasb 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 (ifnecessary) 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-AIASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
Location
Date �, 12 -`f
01 MORTN TOWN OF NORTH ANDOVER
,,N
'. SOL
9
Certificate of Occupancy $
b•,•'o•'c�' Building/Frame Permit Fee $
,SSACNUgE
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
Building Inspector
TOWN OF NORTH ®VER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
�'. �T.�:
BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE: Aa N
Building Commissioner/Inspector of Buildings Date .
.3r1..,ravi1q i -all -E L1VrkjKN L1VP1
1.1 Property Address:
y Grit ro n S 7-r e e
1.3 Zoning Information:
1.2 Assessors Map and Parcel Number:
✓r
ap Number Parcel Number
1.4 Property Dimensions:
Lonmp, Distnct Proposed Use Lot Area Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide Required Provided Required Provided
1.7 Water Supply M.G I C.40. 34) 1.3. Flood Zone Infomration: ].8 Sewerage Disposal System:
Public 0 Private 0 Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System 0
SECJION 2 - PROPERTY OWNERSIUP/AUTHORIZED AGENT
2.1 Owner of Record /
-�TC110 -FT-0
(g r? 16 7 s �t
Name (Print) Address for Service
3 F356
Signature
2.2 Owner of Record:
Name Print
Telephone
Address for Service:
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature
3.2 Registered Home
Telephone
✓ement Contractor/ / ✓ r � / �Og�
Vef
:ompany Name
e
address
T
Not Applicable 0
License Number
Expiration Date
Not Applicable 0
/Do g 3 ,3
Registration Number
02 eu
Expirati n Date
N
SECTION 4 - WORKERS COMPENSATION (NI.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......0 No, ...... 0
SECTION 5 Description of Proposed Work check all applicable)
New Construction ❑ Existing Building ❑ 1 Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ 1 Demolition ❑ 1 Other ) ' Specify
Brief Description of Proposed Work:
P►�vv� !Y
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item I Estimated CostDollaz) to be
(
kTota.:.: ...:,...... ...::em ,.n e.: Sv.::.x,:✓, kk' '.xi`??!:$ Ik kY.$1"$dx-r Kh / 42:w::$:;
l
Building' (a) Building Permit Fee
o Multiplier
al (b) Estimated Total Cost of
Construction
Building Permit fee (a) X tbI
ical HVAC
tection ,
1+2+3+4+5 Check Number
a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner/uthorized Agent subject property
Hereby authorize ( (?Q h1(y ci '1�p b / I 14,(—hct on
My behalf, in all matters relative to work authorized by this building permit application.
Signahue of Owner Date
SEC 7-
1, -
TION 7b OWNERj//AUTHORIZED AGENT DECLARATION
6 1, r 5 ' \ d f �� as Ow er/Authorized AgenPt of subject
propertv
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
a(-_A&s PO b1
Print Nam
Si nature of Own r/A ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TFvvlBERS IST 2
ND
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CTFDNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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Location
No. Date /9'?
A
40RTN TOWN OF NORTH ANDOVER
p Certificate of Occupancy $
41
Building/Frame Permit Fee $
Foundation Permit Fee $
SsacMust
Other Permit Fee3hcY $ c;2 7 "'"
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
Building Inspector
Div. Public Works
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from -
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
**"*********************APPLICANT FILLS OUT THIS SECTION***********************
APPLICANT
/o�! � PHONE_/MP3 ��35o
LOCATION: Assess&s Map NumberPARCEL—
SUBDIVISION
ARCEL
SUBDIVISION LOT (S) �
STREET ST. NUMBER 6
USE
RECOMMENDA T 10 S OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR -HEALTH DATE APPROVED
HATE REJECTED
SEPTIC INSPECTOR -HEALTH
COMMENTS
DATE APPROVED
DATE REJECTED
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR
Revised 9197 jm
DATE
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