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HomeMy WebLinkAboutMiscellaneous - 7 WALKER ROAD 4/30/2018 (5)TOWN OF NORTH ANDOVER Office of the Building Department o��t,�o NORT1i ,bgtio Community Development and Services 1600 Osgood Street, Bldg. 20, Suite 2035 10 41 North Andover, MA 01845 a. ATED k �9SSACHUS���y Gerald Brown, Inspector of Buildings June 7, 2013 To: Shawmut Property Management - Attn: Matthew Dykeman Fr: Gerald Brown Re: Meadowview Condominiums A building permit was attempted to be pulled at Meadowview Condominiums, 7 Walker Road, Unit 11 to remodel a bathroom. During the permit process the question was raised regarding outside ventilation for said bathroom. Based on the 2009 ICC Code Book, Section M1507 Mechanical Ventilation, it is stated under M1507.2 Recirculation of Air, "Exhaust air from bathrooms and toilet rooms shall not be recirculated within a residence or to another dwelling unit and shall be exhausted directly to the outdoors." Please refer to the attached copy of the code section referring to bathroom ventilation. Please call our office at 978-688-9545 with any questions. Sincerely, Gerald Brown Inspector of Buildings Cc: Robert Curtis M1502.4.6 Exhaust duct required. Where space for a •clothes dryer is provided, an exhaust duct system shall be installed. Where the clothes dryer is not installed at the time of occupancy the exhaust duct shall be capped or plugged in the space in which it originates and identified and marked "future use." Exception: Where a listed condensing clothes dryer is installed prior to occupancy of the structure. M1502.5 Protection required. Protective shield plates shall be placed where nails or screws from finish or other work are likely to penetrate the clothes dryer exhaust duct. Shield plates shall be placed on the finished face of all framing members where there is less than 11/4 inches (32 mm) between the duct and the finished face of the framing member. Protective shield plates shall be constructed of steel, shall have a minimum thickness of 0.062 -inch (1.6 mm) and shall extend a minimum of 2 inches (51 mm) above sole plates and below top plates. SECTION M1503 RANGE HOODS M1503.1 General. Range hoods shall discharge to the out- doors through a single-wall duct. The duct serving the hood shall have a smooth interior surface, shall be air tight and shall be equipped with a backdraft damper. Ducts serving range hoods shall not terminate in an attic or crawl space or areas inside the building. I Exception: Where installed in accordance with the manu- facturer's installation instructions, and where mechanical or natural ventilation is otherwise provided, listed and labeled ductless range hoods shall not be required to discharge to the outdoors. M1503.2 Duct material. Single-wall ducts serving range hoods shall be constructed of galvanized steel, stainless steel or copper. Exception: Ducts for domestic kitchen cooking appliances equipped with down -draft exhaust systems shall be permit- ted to be constructed of schedule. 40 PVC pipe and fittings provided that the installation complies with all of the fol- lowing: 1. The duct is installed under a concrete slab poured on grade; and 2. The underfloor trench in which the duct is installed is completely backfilled with sand or gravel; and 3. The PVC duct extends not more than 1 inch (25 mm) above the indoor concrete floor surface; and 4. The PVC duct extends not more than 1 inch (25 mm) above grade outside of the building; and 5. The PVC ducts are solvent cemented. M1503.3 Kitchen exhaust rates. Where domestic kitchen cooking appliances are equipped with ducted range hoods or 488 down -draft exhaust systems, the fans shall be sized in accor- dance with Section M1507.3. M1503.4 Makeup air required. Exhaust hood systems capa- ble of exhausting in excess of 400 cubic feet per minute (0.19 m3/s) shall be provided with makeup air at a rate approximately equal to the exhaust air rate. Such makeup air systems shall be equipped with a means of closure and shall be automatically controlled to start and operate simultaneously with the exhaust system. SECTION M1504 INSTALLATION OF MICROWAVE OVENS M1504.1 Installation of a microwave oven over a cooking appliance. The installation of a listed and labeled cooking appliance or microwave oven over a listed and labeled cooking appliance shall conform to the terms of the upper appliance's listing and label and the manufacturer's installation instruc- tions. The microwave oven shall conform to UL 923. SECTION M1505 OVERHEAD EXHAUST HOODS M1505.1 General. Domestic open -top broiler units shall have a metal exhaust hood, having a minimum thickness of 0.0157 -inch (0.3950 mm) (No. 28 gage) with 1/4 inch (6.4 mm) clearance between the hood and the underside of combustible material or cabinets. A clearance of at least 24 inches (610 mm) shall be maintained between the cooking surface and the com- bustible material or cabinet. The hood shall be at least as wide as the broiler unit, extend over the entire unit, discharge to the outdoors and be equipped with a backdraft damper or other means to control infiltration/exfiltration when not in operation. Broiler units incorporating *an integral exhaust system, and listed and labeled for use without an exhaust hood, need not have an exhaust hood. SECTION M1506 EXHAUST DUCTS M1506.1 Ducts. Where exhaust duct construction is not speci- fied in this chapter, construction shall comply with Chapter 16. SECTION M1507 MECHANICAL VENTILATION M1507.1 General. Where toilet rooms and bathrooms are mechanically ventilated, the ventilation equipment shall be installed in accordance with this section. M1507.2 Recirculation of air. Exhaust air from bathrooms and toilet rooms shall not be recirculated within a residence or to another dwelling unit and shall be exhausted directly to the outdoors. Exhaust air from bathrooms and toilet rooms shall not discharge into an attic, crawl space or other areas inside the building. 2009 INTERNATIONAL RESIDENTIAL CODE' 0 Deems, Maura From: Rob Curtis [zsunset@gmail.com] Sent: Thursday, June 06, 2013 1:20 PM To: Deems, Maura Subject: RE: Contact Email Hi Maura, It was a pleasure speaking with you. Shawmut Property Management of Haverhill manages Meadow View. You can address the letter to Matthew Dykeman of Shawmut. His contact information is below: Shawmut Property Management Attn: Matthew Dykeman 200 Merrimack Street Haverhill, MA 01830 Phone - 800-303-4030 Fax - 978-687-8640 Also, please copy me on the letter by email and regular mail. Thank you for all of your help. Rob From: Deems, Maura Sent: 6/6/2013 1:10 PM To: zsunsetC)gmail.com Subject: Contact Email Dear Mr. Curtis, Here is my email for you to send me the address information. Thanks, Maura Maura Deems Building Department Assistant Town of North Andover 1600 Osgood Street Bldg. 20 Suite 2035 North Andover, MA 01845 1 EXHAUST SYSTEMS M1502.4.6 Exhaust duct required. Where space for a clothes dryer is provided, an exhaust duct system shall be installed. Where the clothes dryer is not installed at the time of occupancy the exhaust duct shall be capped or plugged in the space in which it originates and identified and marked "future use." Exception: Where a listed condensing clothes dryer is installed prior to occupancy of the structure. M1502.5 Protection required. Protective shield plates shall be placed where nails or screws from finish or other work are likely to penetrate the clothes dryer exhaust duct. Shield plates shall be placed on the finished face of all framing members where there is less than 1'/4 inches (32 mm) between the duct and the finished face of the framing member. Protective shield plates shall be constructed of steel, shall have a minimum thickness of 0.062 -inch (1.6 mm) and shall extend a minimum of 2 inches (51 mm) above sole plates and below top plates. SECTION M1503 RANGE HOODS M1503.1 General. Range hoods shall discharge to the out- doors through a single-wall duct. The duct serving the hood shall have a smooth interior surface, shall be air tight and shall be equipped with a backdraft damper. Ducts serving range hoods shall not terminate in an attic or crawl space or areas inside the building. Exception: Where installed in accordance with the manu- facturer's installation instructions, and where mechanical or natural ventilation is otherwise provided, listed and labeled ductless range hoods shall not be required to discharge to the outdoors. M1503.2 Duct material. Single-wall ducts serving range hoods shall be constructed of galvanized steel, stainless steel or copper. Exception: Ducts for domestic kitchen cooking appliances equipped with down -draft exhaust systems shall be permit- ted to be constructed of schedule 40 PVC pipe and fittings provided that the installation complies with all of the fol- lowing: 1. The duct is installed under a concrete slab poured on grade; and 2. The underfloor trench in which the duct is installed is completely backfilled with sand or gravel; and 3. The PVC duct extends not more than 1 inch (25 mm) above the indoor concrete floor surface; and 4. The PVC duct extends not more than 1 inch (25 mm) above grade outside of the building; and 5. The PVC ducts are solvent cemented. M1503.3 Kitchen exhaust rates. Where domestic kitchen cooking appliances are equipped with ducted range hoods or r)il T C,V down -draft exhaust systems, the fans shall be sized in accor- dance with Section M1507.3. M1503.4 Makeup air required. Exhaust hood systems capa- ble of exhausting in excess of 400 cubic feet per minute (0.19 m3/s) shall be provided with makeup air at a rate approximately equal to the exhaust air rate. Such makeup air systems shall be equipped with a means of closure and shall be automatically controlled to start and operate simultaneously with the exhaust system. SECTION M1504 INSTALLATION OF MICROWAVE OVENS M1504.1 Installation of a microwave oven over a cooking appliance. The installation of a listed and labeled cooking appliance or microwave oven over a listed and labeled cooking appliance shall conform to the terms of the upper appliance's listing and label and the manufacturer's installation instruc- tions. The microwave oven shall conform to UL 923. SECTION M1505 OVERHEAD EXHAUST HOODS M1505.1 General. Domestic open -top broiler units shall have a metal exhaust hood, having a minimum thickness of 0.0157 -inch (6.3950 mm) (No. 28 gage) with 1/4 inch (6.4 mm) clearance between the hood and the underside of combustible material or cabinets. A clearance of at least 24 inches (610 mm) shall be maintained between the cooking surface and the com- bustible material or cabinet. The hood shall be at least as wide as the broiler unit, extend over the entire unit, discharge to the outdoors and be equipped with a backdraft damper or other means to control infiltration/exfiltration when not in operation. Broiler units incorporating an integral exhaust system, and listed and labeled for use without an exhaust hood, need not have an exhaust hood. SECTION M1506 EXHAUST DUCTS M1506.1 Ducts. Where exhaust duct construction is not speci- fied in this chapter, construction shall comply with Chapter 16. SECTION M1507 MECHANICAL VENTILATION M1507.1 General. Where toilet rooms and bathrooms are mechanically ventilated, the ventilation equipment shall be installed in accordance with this section. M1507.2 Recirculation of air. Exhaust air from bathrooms and toilet rooms shall not be recirculated within a residence or to another dwelling unit and shall be exhausted directly to the outdoors. Exhaust air from bathrooms and toilet rooms shall not discharge into an attic, crawl space or other areas inside the building. 488 2009 INTERNATIONAL RESIDENTIAL CODE® 0 T- o N ❑cl o U LL m c Q a cu _o U (Q N U U C U 0 N U W Y (1) o U > C) U E Z O U Z c m 0 Q �j C6 U Q �o = Q 3 F.- C O acu E p IL C) o Z F— N cL cu cl Q t E O Y ED WZ N N Q O 70 L O N Z LU Q N N (n ~ L O O4 U m Z C CC _ L a0 -- 0 N r Q Q U) c Q • ♦ o m O ,wpb' O a °U N W 'tet IV m N Q p T • r' � V � Z CN • CULL L U z, C. N M This certifies that ... � ( ,,., , . I/Vl. , he!.� , ...l. . has permission to perform ...�-Z(�. , , , , , , plumbing in the buildings of ... ; . L-t�-'7 . 1'ed ....01//.- at 1/ ,.at .:��/� ��-z% ...,�� , Nrth Andover, Mass. Fee.. Z,%,S.4?Lic. No.. ff PLUMBING INSPECTOR Check #10 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK lug CITY MA DATE- rzl PERMIT # �b JOBSITE ADDRESS `1 W OWNER'S NAME P OWNER ADDRESS Y TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: E] RENOVATION:' REPLACEMENT: PLANS SUBMITTED: YES ® NOF FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM I (. , ►.._.._ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM L.1 DEDICATED WATER RECYCLE SYSTEM I I DISHWASHER i ._...__ _ _ __. —P ..___ .__ _.!J 1-..___..1 ._----! _. I# . _____1 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN AL __.___ _.___._f ___J f 1 ___._.1 ___..___I _-__._1 .___.__! ____. -A____I INTERCEPTOR (INTERIOR) ! I .._ ..I ..__.. ! (_...__ i._.___i KITCHEN SINK LAVATORY ROOF DRAIN 1 _.__.1 i _.._ I l I ._._ .J ._-... f .___-� _.__ ......j --_.J IL—_I SHOWER STALLI SERVICE/ MOP SINK {_- TOILET 1 k _-- URINAL WASHING MACHINE CONNECTION I .._..__ I I ___... J . _ . _I i 1 .- _-1 _.._ _! - _._ 1 _ __I WATER HEATER ALL TYPES WATER PIPING(--- ------- I I I OTHER f fi ( _ � i ...-.....- INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES jIj NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ej OTHER TYPE OF INDEMNITY ' BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER M AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be ' compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r PLUMBER'S NAME Qom% A_ �M A r�P � LICENSE # aZd o , - ( ` a ATURE NIP 0 JP t4 CORPORATION ©#� ,, PARTNERSHIP Q# _ LLC �I COMPANY NAME ADDRESS CITY lu h �acZ� _. _ j STATE ZIP D i x'15 !I TEL FAX CELL _�� EMAIL — - ----- - -- - ._-- --..._ -- --- -... _ r H z° 0 F U n� w a i N W o o z z �El O W a z u _ 3 O aa oLU w co O z All a � w a � U J a IL a Oj s w f- w rA W F O O F v a z � M a c�7 The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �)9c\')1\ �\A' V% 1n,A Y\ Address: I t/\)0_0e V\ qA , y City/State/Zip: % Ao 5,hu 1-U 1>18-2y Phone #: Q 76 -4g0 -((0q& Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. 11 am a sole proprietor or partner- listed on the attached sheet. hip and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. El Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. [1 Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they aie 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). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under flee pains and penalties of perjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone Information and instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract 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 related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department o#'Industrial .Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 Tel, # 617-727-4900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax # 617-727-7749 wwW-mass,govfdia r a� u6ig LU m �+ W V w Z:..; co:::: w CA w z az Q o~ Z-0 m as W Qz Z A Ln o Lu Q CO co D Q Z o gW S2 Men 3 Q o -jz aU Z. p 3 N n N - < CD :j o } Date .......... �-4:nX3 .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........:.•e� ...... .. ZZ(� ..... �tl has permission to performA, �-� ZI-ef 00 A.471 . . . ................................... wiring in the building of. .............. 5 **** ............... at .................... C orth Andover, Mass.. .... e Ae .. . ...... P ........ ............................. 'Fee ..... Lic. No..,.k.4 Check # 4)L L z -k iluoj Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. % S 1 , 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 �J d (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: 7. tT—o City or Town of: NORTH ANDOVER To the Inspector of Wires: i By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) -7 ()cZt/&&. t3 n tT /l Owner or Tenant[, �1 b L V r i'i .S Telephone No. l Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 13A4 -h "VA tt a plyyr%/ Utility Authorization No. - Existing Service _/J�0 Amps /?13/ acvVolts Overhead ❑ Undgrd 0-- No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: A& J ao 6"++A ('mmn1Ptinnnfthofnllnwirntnh7.,, In, 1I...A T � lLTR No. of Recessed Luminaires / ----t---"-'• �..-��.•.-....6. No. of Cell: Susp. (Paddle) Fans . yv 1 r vJ rrrrw. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o mergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burgers No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Number ' ' " Tons " ' ""'""" KW """""""""""' No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW ILocal ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices 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: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: /13 , rp (When required by municipal policy.) Work to Start: 9—y—/_3 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 ' orce, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) I certify, underthe an ,penalties ofperjury, that the information on this application is true and co fete. FIRM NAME:. Jv� 744 A•�jVD � ��-� L LIC. N • Licensee: t �j"" ��1, ��a SignatureAst LTC. NO.: (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: Address: _ 3),fln�c�, oeJ ►Z3 Ch.t/,,,sArd In,4 611d. y Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety" 'S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed:** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: . E Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass IF Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: �� ,i�� Date: ROUGH INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INS TION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: G , Inspectors Signature: Date: 9-2_ 7-1 -v DEB WEINHOLD ... TOWN OF MER AC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department oflndustrialAccidents Office ofInvestigations 600 Washington. Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ' Please Print Legibly Name (Business/Organization/Individual): t.JyG V I I CCheT70 G14G n C, Address: 3 0)1 City/State/Zip:_ Cti e l m sArr. A1� c) 18) y Phone #: J `f/c4 Are''Iyoou.. employer? Check the appropriate box: - Typo of project (required): 1. am a with employer ['-1 —� 4. ❑ T am a general contractor and I 6• ❑New construction ' � employees (full and/orpart-time).' have hired the sub -contractors 7. 6 -6 -modeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet.1 ship and'have no employees These sub -contractors have 8. ❑ Demolition working for mein any capacity. workers' comp. insurance. g, ❑ Building ad ' ' n [No workers' comp. insurance 5. ❑ We are a corporation and its 10. ectrical repairs or additions required.] 3. ❑ I am a homeowner, doing all work officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and wehave no 12.❑ Roof repairs _ insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] 'Any applicant that checks box #f must also fill out the section below showing their workers' compensation policy information. 7 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. -Taman employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. � Insurance Company Name:. 271C fit' RI ,f y—cl Policy # or Self -ins. Lie. #: Expiration Date: 7-31e- /,SV Job Site Address: 7 4INk-1' ki)yvi i T' I/ City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to .$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of 'Investigations of the DTA for insurance coverage verification. X do hereby cel under the pains andpe,qalties ofperjury that the information provided above is true and correct. — E`13 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. CitylTown Clerk 4. EIectrical Inspector 5. PIumbing Inspector 6. Other - - - Contact Person:_ Phone Information and InstructRons 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 ofthe 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 -contractors) name(s), address(es) and phonenumber(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 maybe submitted to the Department of Industrial Accidents for confnmation 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 fillgd 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 fox 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 Comm. 0-UM61th ofMassachvsetts Dap.artment oifndustrial Accidents (Office o£Inyestigatio.m 600 WasbiWou Street Boston} MA 02111 TOL # 61.7-727-4900 at 406 or 1-877-MASSAFE Revised 5-26-05 Fax W 617-727-7749 _mace an•c.�i�;a