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HomeMy WebLinkAboutMiscellaneous - 790 TURNPIKE STREET 4/30/2018N o � CC vZ Q m o Cf) as ; �p m o�^i Date... TOWN OF NORTH ANDOVER . PERMIT FOR WIRING This certifies that .................. . ................................... ................. I ................................................. has permission to perform.,/...... q-..111jj.k.....-t . ..... ... . wiring in the building of ..... .......................................................................................................... at .........—7 ...................................................... 1 ......................................... I North Andover, Mass. 73 Fee/1. ............. Lic. No..2.F., ELECTRICAL INSPECTOR Check it 12 7 8 5—/ Commonwealth wealth of Massachusetts Official Use Only Department of Fire Services Permit No. i Occupancy and Fee Checked a BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRMT 1NINK OR TYPE ALL INFORMATION) Date: 14-d6-15- City 4-d 6•ICity or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersignedJives, notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address 1^6 Telephone No. Is this permit in conjunction, with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building � %1 63 rGlcc�l Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd [:1 No. of Meters Number of Feeders and Ampacityw-hli I0 Location and Nature of Proposed Electrical Work: UP Completion ofthe 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- E]o. rnd. rnd. o mergency ig ting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I 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 No. of Dishwashers Space/Area Heating KW Local ❑ Municipal E] 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 E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: S&I, 0 (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 PBOND ❑ OTHER ❑ (Specify:) L %jj& L%i7'JgUMj1-1 X certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME:. AmL Paz&t/ ewef a /L' J' vlu- LIC. NO.:l�u Licensee: 147 � & 2V Signature LIC. NO.:V/ 7-? (If applicable,ente "exempt" in the license number line.) Bus. Tel. No. • r 1 sl Address: 0 L 14A ;9 Vi-, n EI -7-10W ,%M 6> R, 1i 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 PEAMIT FEE: $ Signature Telephone No. t ❑ 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 M 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 0 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 ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: q 44 41 Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com 14, The Commonwealth of Massachusetts Department of IndustrialAccidents X Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers, Compensation Insurance Affidavit- Builders/Contractors/Fieodcians/Pli tubers. TO BE FILED WITH THE PERMITTING AUTilORITY. Name (Business/Oigabization/Ind'vv dual): K K - Address: d 2 / n) A () � U r - City/State/Zip:_ Are you an employer? tiie appropriate box: 01 kq q Phone #: 1. P-1ain a employer with _employees (full and/or part-time . 2. ❑ I am a sole proprietor or partnership and have no employees vvorking for me in any capacity. [No workers' comp. insurance required.] 3. Q I am a homeowner doing all work myself, [No workers' comp. insurance required.] t 4.1 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. Q 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 ofproject (£equired): 7. ❑ New'd6nstr6dion g. [] ].Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. ec4ical repairs or additions 12�[] Plumbing repairs or additions 110 Roof repairs 14.10 Other *Any applicant that checks box #] _wrist then hire outside contractors must submit a ne also fill. out the section below showing their workers' compensation policy information. I Homeowners who submit•tbis affidavit indicating they are doing all work and w affidavit indicating such. st attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have $Contractors that check flus box mu employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. X am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Expiration Date: Policy # or Self -ins. Lie. Job Site Address: % 64 xp��J'01 1� City/State/Zip: ✓kv) Attach a copy of the workers'compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL e. 152, §25A is a criminal violation punishable by a foie 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. X do hereby certify under hepains a enalties of perjury that the information provided above is true and correct. . 7 n �; .__ - is �� -/S one # C- l d �j YO official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License 9. Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Phone #: -b Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their eaiiployees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of h_ ix'e, 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'& 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 prod -aced -acceptable evidence of compliance with the insurance coverage xequired." 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 thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "fob 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-NIASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia ol844-45 22,� n -5 �o Lb IL IL 0)r, I co Co N n 01 d U D W) I - Z W Z O 2 � U) d U) - • Z W (n �= O D ,U L% -A X m 7 O>o d > 9546 Date ...... Ta J, TOWN OF NORTH ANDOVER PERMIT FOR WIRING Sswcwus Thiscertifies that ............................................................ .............................. has permission to perform .......... ...... 0-7 wiring in the building of ...... ...... ............................ P /0: Z: at ..... 71 ............................. lf-7. North Andover, Mass. Fee .... Lic. No.'�� .. .......... �iiCZ(A� i�S�E��R Check �Y �•� �.wnmvnwca►in v► ►�ia��a�uu�caw -- --- --- ----� Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: .1 1-r-,� �, )-,� '21 0 /0 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number)�� Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes Purpose of Building Telephone No. No ❑ (Check Appropriate Box) 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: h4141 t1j1"JA6" � `yma 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-E] rnd. rnd. of o Emergency Lighting 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 Devices No. of Ranges No. of Air Cond. Total Tons —Initiating No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number. Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW 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 E uivalent OTHER: (/�'' Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Plectrjpal Work: ® (When required by municipal policy.) Work to Start: J 0%0 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE OV 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 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 an penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: _ Licensee: �/O�� �jyp p.0 Signature LIC. NO.: /�� 7I/ (If applicable, enter "e empt" in the license number line. / Bus. Tel. No. - 2t/ 35- Address: �l .Y �' 4) jir/,`7�L�✓ jQ, "� 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 Owner/Agent PERMIT FEE: $ Signature Telephone No. The Commonwealth of Massachusetts qU,V Department of Industrial Accidents Office of Investigations 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):/�J/✓ I �/�,%%'d/ ��j f� j�/��'►� %�/� Address:_ /00 /Se, -`e E. P J 1t/019W-0--j City/State/Zip: � "'✓ � Phone #: �I `s/ .7 W� Are you an employer? Check the appropriate box: I am a employer with 4 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. 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 3. ❑ I 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.;r Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. El Plumbing repairs or additions 12.❑ Roof repairs 131?fOther 40"1114 ;r'W *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and 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: �l Policy # or Self -ins. Lic. #:Gy���''I �S/� Expiration Date: 471 A7 Job Site Address: / I �yi��� tl �. City/State/Zip:/O, 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 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 certiMnde the pain gdFd p9nalties of perjury that the information provided above is true,and correct. Signature:�qice- st Date•li/;/�J� Phone #: / �i 7 % It f `b/l��/- 2k1 -7,35- , 5 - ^% 7 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 #: •� 1 Y The Commonwealth of Massachusetts -,7 Department of Public Safety BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 1200 Office Use Only _7// .Permit No. Occupanq+ & kee Checked©V " 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK - = All work to be performed In accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORHATION) Date City or Town of�j/.�� �Aotc,<, To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) OGrer or Tenant Owner's Address 7 i Is this permit in conjunct N:*;.V Purpose of Building Existing Service Amps Volts New Service Q 6 Amps 026 / / /Q Volts Number of Feeders and Ampacity Utility Authorization N0. :Z20,5,73 Overhead ❑ Undgrd ❑ No. of iSeters Overhead ❑ Undgrd [P""' No. of Meters Location and Nature of Proposed Electrical Work -7--,,.s / - Q � 12445'1'41' ZO No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total r:VA No. of Lighting Fixtures SwimmingAbove Ir.- Pool grnd. ❑ grnd. ❑ Generators KVA No. of Receptacle OutletsNo. of Oil Burners lBattery No. of Emergency Lighting Units No. of Switch Outlets No, of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No, of Sounding Devices No. of Self Contained Detection/Sounding Devices Municipal ❑Other Local ❑ Connection No. of RangesNo. of Air Cond. Total tons No. of Disposals No. of Pumps Total Total Tons KW No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KW No. of Water Heaters KW No, of No. of Signs Ballasts Low Voltage Wirin No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws T_ have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES C] NO E] I have submitted valid proof of same to this office. YES ❑ NO If you have check YES, please indicate the type of coverage by checking the appropriate box. INSURANCE BOND ❑ OTHER ❑ (Please Specify) (Expiration Date Estimated Value of Elecrrical Work S y i 4)_j Work to Start Inspection Date Requested: Signed under the penalties of perjury: FIRM NAME_�/iT� Rough Final LIC. N''). g ' Licensee Signatur-- ��z ,-„ LIC. NO. Address �� f7 Bus. Tel. No.````—�=B—a5 � •, Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am -aware that the Licensee does not have the insurance coveeage-"c stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement.. Owner Agent (Please check one) t Telephone No. PERMIT FEE S / Signature of Owner or Agent { .T Date..: =Q- 71 ry o�°;�;``°-,°�"°°� TOWN OF NORTH ANDOVER Q PERMIT FOR WIRING ¢ _ 4Lr ~' SSACMUS� 3 This certifies that ................. .... . . . ... J.e. W.... M a has permission to perform ~r ..... �.i� ................. 4— :r.... "" r ?. wiring inthebuilding of .......1 at ...........,l../......... r✓ ... f ,North Andover, Massa Fee 0. Lic. No -���AD...................................... ; ELECTRICAL INSPECTOR r _ 4? WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 8