HomeMy WebLinkAboutMiscellaneous - 70 PEMBROOK ROAD 4/30/2018-9526
Date ........
49
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............ ................ I .....
has permission to perform .......... I 13w,�---e----,o ...............................................
wiring in the building of ....................... .............
,7..... 12 j
at ........................ .0 ..... eb ........ ;,o, -Nor )Andover, Mass.
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Fee ..S. Lic. No. .•B CTRICALINSPECTOR
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Check It
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❑ 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 shaWL-e uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by ar In`3pector of Wires appointed pursuant to M. GI 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_Tnspector-of_Wires abandoned.and.invalidifhe.___.
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 entitystated 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-tern 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: ** Dote: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed!
a.vinmwiwcaicn w rias�ac,iiu�c�w
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Permit No.°�
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 Cod (MEQ, 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: -7120 ZU 10
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his her tention to perform the electrical work described below.
Location (Street & Number) b 1911—le %j `
Owne or Tenant ci 1 k a 1 c Telephone No.
Owner's Address 70 _�k C,1 rv_ C_ i2 /
Is this permit in conjunction with a building permit? Yes [T No ❑ (Check Appropriate Box)
Purpose of Building St PJrt -�" t Utility Authorization No.
Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: `S+ Fw- a T i 3]q br rad /•1 re -pa v,,+i o,,-,
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- El
rnd. rnd.
o Emergency Lighting
Battery Units
No. of Receptacle Outlets �` FGt
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of SwitchesNo.
of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
g
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
Heat Pump
Number
.........................................................
Tons
KW
No. of Self-Contained
Totals:
Detection/Alertin Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances Kir
Security Systems:*
No. of Devices or Equivalent
No. of 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: % —COM 6 / 11 �� ft oo
�
Do ,rte Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value o Elec ical Work: / (When required by municipal policy.)
Work to Start:7/1 9 10 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COV GE: 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 cov, rage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains andpenalties of per�j+u"ry, that the information on this application is true and complete..
FIRM NAME: 1 " L JF&e 71 C (� _ MC • LIC. NOA4 50
Licensee: 1444 V ( W, .SDt r(T Signature to - int 4jr-i LIC. NO.& S0 3/3
(If applicable, enter 'exe pt" the lic nse number 1y' �e.) '' FF / y Bus. Tel. No.• �.5" 722
Address: /%3 � �✓t ` S'ti/ I lV• rl ° 0 / Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, gecurity 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
Owner/Agent PERMIT FEE. $
Signature Telephone No.
Y
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e
a
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
t •
s � a
,SSACHUSf
This certifies that .. �G e. Y....LI.U.C. C i? f ....... .... .
has permission to perform .... ..............
plumbing in the buildings of . 1?%4:7.. y.o �-." .S................ .
at. North Andover, Mass.
Fee. Lic. No..7 . ...... ..............
3 / IPLUMBING INSK TOR
Check .* f S J
8376
-MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,MA.SSACHUSETTS 3y`y A .I0
� ` nDate
Building Location 7C P/Yf Ui� Owners Name f %'"-1
ernnit # "
5 Ht✓. '�•/�(/Vl � u Amount
TvDb of Occupancy
0
New [ Renovation Replacement Ll Plans Submitted Yes No
' -.-ilflTmTTTT C '
(Print or type) I% Check one: Certificate
Installing Company NameC'AfV !`� (��' �� Corp.
Address
AQ El Partner.
k &,A.
Business Telephone "l _ Firm/Co.
Name ofLicensedPlumber:_ L�WLII==`E's
Insurance Coverage: Indicate the type of insurance coverage by checking the box:
Liability insurance policy Other type of indemnity Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
rgnature Owner Agent
I hereby certify that all ofthe details and information I have submitted (or enfered) in above application are.true and accurate to the
best of myknowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions ofthe Mass husetts Stateoumbing Code and Chapter 142 ofthe General Laws.
Title
CitylTovtam
APPROVED (OFFICE USE ONLY
3 (ype 0 Plumbing License
rcense um er Master
Joumeyman 15
R
i�
t�.
The Commonvealth OfAlassachusetts
Department. Of.£radust-ialAccidents
Office of j-xvesi gations
' 60.0 Washington Street
Boston, 3U a211l
x�rtrlv_nzcrs�gov/dna - .
Workers' Compensation Insurance _Affidavit: guilders/Contractors/Electt-icians/Plumbers
I rpplicautInformation
Name (Business/Orb nization/Individual):
Address: ' '
City/State/Zip:
Phone #:
employer? Check the appropriate box:
employer with.
4. ❑ I am a g� eral contractor
yees (full and/or part time).*
sole proprietor or
I
and I
have hired the sub -contractors
Misted
partner-
on the attached sheet I
nd have no employees
These sub -contractors have
g for mein any capacity.
workers' comp. insurance.
orkers' comp. insurance
5. ❑ We are a corporation and its
d.]
3. F-1.1 am a homeowner doing work
officers have exercised their
all
myself. [No workers' comp.
right of ex:empfion per MGL
c. 152, §_J (4), and we have
insurance required.] t
no
employees. [No workers'
comp. insurance required.]
C�t tja: Check- bo Ai m-_� j aiS.1 fin L` , f::.� Sw"L�� be,,Ol': E.^.0::^..^.s `^^; v,�Cfi:aS` COIL oer:.,..
Flarneown
Type of project (required):
6. ❑ Nein construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
I0.❑ Electrical repairs or additions
.1 L ❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
ers wno sunmrt uns affidavit Indicating &, are doing alt .w r— `'M
`a when hire outside coat*zcto s gist ;u,,, it a new amdavit indicating such.
Contractors that chw k bot, z, q an addirionai sheet showing the
name of the sub -contractors and their workers' comp. policy infcan tiara•
-ram an employer that is providing workers' cornpensaiion irzsurance for my employees Beloit is the policy and job site
information,
Insurance Compiny Name:
Policy # or Self -ins. Lic. #.
Expiration Date:
Job Site Address:
' Ci /State/Z'
Attach a copy -of the workers' compensation policy declaration .page (showing the policy number,and expiration date).
Failure to secure coverage as required under Section 25A ofMGL G. 152 can lead to the imposition of criminal penalfies of a
fine up to $1,500.00 and/or one imprisonment, as well as civil penalties in the form of a STOP WORK ORDER ars a, a
n es to S250tions 0 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
fme
Investigations of the DIA for insurance coverage verification.
Ido hereby certify under the pains and penalties ofp'erjurJ' 64r -'the information provided above•is true and correct
Siffiature:
Dater.
Phone4. ` 70K 3`1'5 � D � � _
Official use only. Do not write'in this area; to be completed by city or town official
City or Town:
Issues Authority (circle one):
1. Board of Health 2. Building Department
6. Other
Contact Person:
P ermitUcense
3. City/Town Clerk 4. EIectrical Inspector 5. PIumbing Inspector
Phone •#:
Information an- d 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 conu•act of hire,
express or implied, oral or written."
An employer is defined as "an,individual, parinefslup,•associar_tion, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including tie Iegal representatives of a deceased employer, or the
receiver or trustee of an individual, pal-tership, association ax- other legal entity, employing employees. However the
owner of a dwelling house having not more than three apar(imL encs and who resides therein, or the occupant of the
dwelling house of another who employs persons to do mainte ranee, 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 ear ployer."
MGL chapter 15.2, §25C(6) also states that "every state or Ioacal licensing'agency shall withhold -the issuance ar
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 co-vmpliance 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.perfonnance of public work urt=itil acceptable evidence of compliance with the insrance
requirements of this chapter have been presented to the contrawting authority.,,
Applicants
• Please fill- out the workers' compensation alEidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-coniractor(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
re
members or partners,. anot required to carry workers' comp cnsation insurance. tan ce. 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 rxxre'to sign and date the affiidavit. The affidavit should
r_- the pe +cense + being red tested,' fiat fW >
e re uueu 8�%licauuu cvl r�it'or li 4
industrial Accidents. Should you. have =y questions _egg. � a i •' ' wor1cros of
hn � i have r r1+`s �„ la�i lJ1 if you aYe r�sired to obtain a workers'
compensationpolicy, please call the Department at the numbed- 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 ad4ition; 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
(Le. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit
The Office of Investigations world b1m to than you in advance for your cooperation and should you have any quesfions,
please do not hesitate to give us a calL
,� r
The'Depariment's address,'ielephono zndfimnumber._..
'Z b e Com-mQniwealtt of Massa.chuseftg
Department oflndu&trial Accidents
Ofrace of In esttic ati ons
500 Washiitg-�:ton Street'
Bostaa., M -A 02111
Tel. # 617-727-490.0 ext 406 or 1-9 77-1\LASS:AFE
Fw. #6-17-72)7-7749
Revised 5-26-05 vrww,mass._(rov/dia