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Home My WebLink AboutMiscellaneous - 76 HILLSIDE ROAD 4/30/20180 0 w n 0 _o 0 0 0 0 0 � -- This certifies that .. .. .... ... . 01, Ems Ic_. ( has permission to perform. wiring in the building of t. %Q rAS`r'".............. at .............. `\� `�S�.0 ?-..1�� ; No Andover, Mass. Fee �` . Lic. No1�'�^'?. .��,!..... ELEC�'RICAL INSPECTO Chect # 11370 A Commonwealth of Massachusetts Department of Fire Services a BOARD OF FIRE PREVENTION REGULATIONS Official Use Only 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 Electrica41nsppe C), 52. CMR 12.00 (PLEASE PRINT IN HK OR TYPE ALL INFORMATION) Date:I � 1 � City or Town of: NORTH ANDOVER To ther of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) --X Hl Itiyd p Di Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service 2,-m Amps RO / 2,io Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: W; All raoc6r �5 , w,� g I��Jb�Gt Dyc4iYsS W+Lc 1 Sic ovt� Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell.-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- E, rnd. grnd. No. o mergency 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 No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number .....' Tons .............."""' KW """"""'""""' No. of Self -Contained Detection/Alerting Devices 1No. of Dishwashers _ o. of Dryers Space/AreaMeating KW HeatingAppliances KW PP Local ❑ Municipal ElOther Connection 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 IIP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of YYires. 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 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:) Icertify, under thepains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME:. v� LIC. NO.: Licensee: S G f`I� rt— Signature LTC. NO.: 173 �sZ Fl (If applicable, enter "exempt" in the license number line) Bus. Tel. No. - Address: 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: r Trench Inspection Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass n Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed IN Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass_0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: I Inspectors Signature: Date: FINAL INSPECTION: Pass EN Failed 0 Re- Inspection Required ($.) ❑ Inspectors Com Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations kvi 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciaas/Plumbers Applicant Information// Please Print Leeibly Name (Business/Organization/lndividual): Address: aso City/State/Zip: t� �� 3 Phone #: Are you an employer? Check the appropriate box: 1. [R 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. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship 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 3111 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. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.® Electrical repairs or additions 11:❑ Plumbing repairs or additions 12.0 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 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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. f Insurance Company Name:.iN Policy # or Self -ins. Lic. #: 76 W el TV 5YFZ Expiration Date: Job Site Address: %� { �,�ilSitlP 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c ertify under the pains and penalties of perjury that the information provided above is true and correct. Sil?nature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone 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 -contractors) 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 Gomuxroxawealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 61.7-727-4900 ext 406 or 1.-877rMASS.AFE Revised 5-26-05 Faze # 61.7-727-7749 wwwjuass.gov/dia .,d i A I Date ......p?.. .. �� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that........................�...........:%%. ...................... has permission to perform ............ ......................................................................... IeN wiring in thebuilding of ........................................................... at..................J.............. North Andover, Mass. 4;e- Fee�So..............: Lic. No....7-7 -% ........r. � .......... .�1r....... ELECTRICAL INSPECTO Check # + � � �' b(// 1300r 4 , lf1mmonwea,19 of Ma66acku4ei Official Use Only 77 n Permit No. ®, eLJe,part`ment ol5ire Serviced Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank)' APPLICATION FOR PERMIT TO PERFORIN ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.,00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATIOA9 City or Town of: By this application the undersi Location (Street & Owner's Tenant L'Y nems Address _ Is this permit in ca Purpose of Building 42 Existing Service Ams / Volts Overhead ❑ Date: To the Inspector of Wires: :rform the electrical work described below. Utility Authorization No. New Service Amps / Volts Overhead ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: .Undgrd ❑ Undgrd ❑ No. of Meters No. of Meters Completion of the followinz table may be waived by the Inspector of Wires, No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. Total' Transformers KVA . No. of Luminaire OutletsNo. of Hot Tubs Generators - KVA No. of Luminaires Swimming Pool Above ❑ In- g rnd. rnd. o. o Emerge Lighting . Battery Units No. of Receptacl O t_ 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 Tot No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: ...,-umber Tons -M.........._..- KW -Detection/Alerting No, of Self -Contained Devices No, of Dishwashers Space/Area Heating KW Local ❑ Municipal El other Cyonnection No. of Dryers Heating Appliances KW SecNo- of Detvi es or Equivalent No.. of Water Heaters KW No. of o. of Signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications firing: No. of Devices or Equivalent OTHER: 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: _? - 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 4 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:) I certify, under the pains and penalties of perjury, that the information. on this application is true and complete. FIRM NAME: �,� 4�o e� GG frr LIC. No.: Licensee: `Cf �; G��jyr�SU Signature ep LIC. NO.: s (If applicable, enter "exempt "in the license number line.) Bus. Tel. N Address: �4f /)a�JG' f%/Fs4,a 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 Signature Telephone No. PERMIT FEE: $ L J Vie Conurionivedlth ofU6ochusetts Department of Industrial Accidents Office of Investigatials 600 Kashington Street Boston, MA 02111 iviviv. niass.go vId is Workers' Compensation Insurance Affidavit: Builders/Contractor-s[Electricians/Plutubers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 2�Z.�t3 Address: _Z /)&bo o ,' City/Stale/Zip: ®f&'yf Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a'employer with _ 1- 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheell t ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation 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.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition .101211Electrical repairs or additions 11.❑ Plumbing repairs or additions 121-1 Roof repairs 13.❑ Other f*Any applicant that checks box #t must also rill out the section below showing their workers' compensation policy inronnation: J Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such Icontractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. . lam an employer that is providing workers' compensation insurance for my employees. Belo iv is the policy and job site :information. Insurance Company Name: N Policy # or Self -urs. Lic.. M '4490 / 7. % Expiration Date: Job Site Address:%f,�f .�� '��Y/'� % � City/State/Zip: /l�• /,�,� �)Dd ; All 4 , Q/ter, *b 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 of MGL c. 152 can lead to the imposition ofcrintinal 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 dayagainst the violator. Be advised that a copy of this statement may be forwarded to the Office of 1 Investigations of the DIA for insurance coverage verification. 1 do hereby ceilify under the pains and penalties of perjury that the information provided above is true and correct. Phone #: Official use only. Do not write in this area, to be completed by ci07 or toren official. City or Town: Perinit/License # Issuing Authority (circle one): 1. Board of IIealth 2. Building Department 3. Cityrrown Clerk 4. Electrical Inspector 5.. Pluttibing Inspector 6. Other Contact Person: Phone #: ?- 9- 6.7 Date .-- � ..c.�.......................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... .. ....... �? ........ ................................................ .... ............... has permission to perform --:��,-Alqt,-,,94- ;T, - (--/, �* .... *'*,#***********""****"I*"*"*".Iy .................... wiring in the building of ....... . ..... ................................ 9�/,�- P. ...... e at .............. . Norffi.,kndover, Mass. ..... ..................................................... ,0- 6IJ - Fee...K. .......... Lic. No.,gz,-?l S ') , ........... ................ ELECTRICAL INSPECTOR Check # 7273 Official Use Only Commonwealth of Massachusetts y Permit No. �2 Z3Department of Fire Services Occupancy and Fee Checked 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 (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1 0 9w 7 City or Town of: NORTH ANDOVER To theIn pector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 12.1 Owner or Tenant ,�P✓t iJ �i��r� ,x9s l Telephone No.9;2, 6 FT,73r'/ Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No [5 (Check Appropriate Box) Purpose of Building )O.P 46e, r, Utility Authorization No. 0'1 a d D O a 9 Existing Service o Amps /aa Volts Overhead Undgrd ❑ No. of Meters New Service Amps Volts Overhead Undgrd ❑ No. of Meters % Number of Feeders and Ampacity 1 _ /o p A�,�, Location and Nature of Proposed Electrical Work: Lf,M rA- V s Y 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- ❑ rnd. grnd. o. of Emergency Lignting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. o Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Number. Tons KW No. o Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Munic'pal ❑ Other Connection No. of Dryers y Heating Appliances KW 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: 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: ;V2d -7 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE OV , RACE: 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 2*' BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and a/nalties of perjury, that the information on this application is t e and complete. FIRM NAME: 1--�-11i r-711ic'd _Zg%) & LIC. NO.: /07K 3 / Licensee:f-j, G �� Signature `�� LIC. NO.: oLa (If applicable, enter "exempt'" in the license number tine.) Bus. Tel. No.:Q27 !?150RF- %V Address: 9�7 - iv v S4�. S&., Gc Al(" 0" 61 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safe "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 Signature Telephone No. PERMIT FEE: $ Gq