HomeMy WebLinkAboutMiscellaneous - 810-812 Salem Street (6)NORTH
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APPLICATION FOR CERTIFICATE OF OCCUPANCYIINSPECTION
Buildina Permit # 5-75
ADDRESS/LOCATION OF PROPERTY : 7 .a t
Map Sr Parcel i Lot Number /s
SUBDIVISION
DATE REQUESTED FILED/READY FOR INSPECTION %�
CLOSING DATE ON PROPERTY:
—:�4-4-
FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED
ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE-
INSPECTION FEE OF TWENTY DOLLARS $20.00) WILL BE CHARGED IF THE STRUCTURE
DOES NOT MEET ALL APPLICABLE CODES.
Permit Issued to:v's�-2�u
Address
CONSERVATION
PLANNING
DPW - WATER METER
Q' -rA-f /) y
SEWER/WATER CONNECTION E12�.
NOT
DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO
SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST
DPW
Fite: Application for OC form revised Jan 2007
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER.
Building Permit 573 (3/3/08 Date: December 17 2008
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 810 Salem Street
MAY BE OCCUPIED AS Single Family Dwelling - IN
ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING
CODE AND SUCH OTHER REGULATIONS AS MAY APPLY.
Certificate Issued" to: John Carroll
1501 Main St
Tewksbury MA 01876
Building Inspector
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APPLICATION FOR CERTIFICATE OF OCCUPANCYIINSPECTION
Buildina Permit # 5-7 3
ADDRESS/LOCATION OF PROPERTY: 57( D 57
Map � 5 Parcel ( Lot Number ls' _,
SUBDIVISION
DATE REQUESTED FILED/READY FOR INSPECTION
CLOSING DATE ON PROPERTY:
FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED
ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE-
INSPECTION FEE OF TWENTY DOLLARS $20.00) WILL BE CHARGED IF THE STRUCTURE
DOES NOT MEET ALL APPLICABLE CODES.
Permit Issued to: -JO-9/0 A�le-z�
Address /r i �� /� s>', # �� -11FAhK 32n y_
CONSERVATION
PLANNING
DPW - WATER METER
SEWER/WATER CONNECTION E12'
NOTE
DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO
SUBMITTAL OF THE OCCUPANCYIINSPECTION REQUEST
DPW
Fite: Application for OC forrn revised Jan 2007
Date. .....� .................
°,,`' TOWN OF NORTH ANDOVER
' PERMIT. FOR WIRING
. This certifies that ....�?SEC..e-'(.....'.............................................................
has permission to perform ..�' `�'..''1.!` ...,��"�!!�!.�.............
wiring in the building of .. kV .. S%
�n,��
at............................................................................. .North Andover, Mass.
A93-3r-I&Fee...': • ......... Lic. No .............. ..................-�,......
LECTRICALINS TOR
Check # ��
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Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. r C)
Occupancy and Fee Checked
[Rev. 1/0.7] (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 WINK OR TYPE ALL INFORMATION) Date:S 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) g/Q Sj /.tm
Owner or Tenant q4AJ GA&D ff K-In's Telephone No.
Owner's Address ISTD/ in, i.,xc %,d. ic-—r—..La 1_..:., _ ,.tom_ isr7i
Is this permit in conjunction with a building permit? Yes LrJ No ❑ (Check Appropriate Box)
Purpose of Building 2s fes✓ Utility Authorization NoTi%•,P
Yc
ervice DO Amps //D / 4wo Volts Overhead Undgrd ❑ No. of Meters %
New Service o?00 Amps //D / Z -?v Volts Overhead �� Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
^� --- --on- aerau q aestrea, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (,(,(/. EiZ7 (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 cove ge is in force, and has exhibited proof of same to the permit issuing office..
CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:)—i/ %
A fs`vCC Gv ,� G
I certify, under thepains andpen allies of perjury, that the information on tdis!Zpr'014tc;0iE=ion is true d co�plete.
FIRM NAME: 1 S G 2i'C LIC. NO.: /y ,53 r -B
Licensee: 1 cyie T �A1�TSigna ture LIC. NO.: / D.33y 4
(If applicable, enter "exempt" in the license number lin
Address: Bus. Tel. No.: ' b' �7
*Per M.G.L c. 147, s. 57-61, security work requires Dep ent of Public Safety "S" License: Alt L cl. No. 972 ` SS-G3�3
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: $
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„. The Commonwealth of Massachusetts
- ! Department of Industrial Accidents
Office of Investigations
s;li 1 I' 600 Washington Street
Boston, MA 02111
{ ' www.nmss.gov/dia .
Workers' Compensation insiurance Affidavit- Builders/Contractors/Eiectricians/Plambers
Applicant Information Please Print Le�bly
Name (Business/Organization/individual):
Address:S r jo4210NC E Ave-
City/State/Zip.,
veCity/State/Zip:
of$_X
Phone #:. % j ' ?Dt f - 71-0
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and 1
,employees (full and/or part-time).*
have hired the sub -contractors
2. I am a 801 proprietor or partner-
listed on the attached sheet i
ship and have no employees
These suit -contractors have
working for me .in any capacity,
[i*10 workers' comp, insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
3. ❑ 1 am a homeowner doing
officers have exercised their
all work
right of exemption per MGL
myself. [No -work ers' cotrip.
c.. 1.52, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.l
'Any applicant that checks bo): #I must also fill out the section below show;- the' rk ts'
Type Of Project (required):
6• �ew construction
7. ElRemodeling
8. [] Demolition'
9. ❑ Building addition
10.❑ Electrical repairs or additions
I I.[] Plumbing repairs or additions
12. ❑ Roof repairs
13. ❑ .Other
g tr wo a compensation policy intonnation.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContructors that cheat this box mustattached an additional shmrshowing time e of the sub-conttactom and their workcnt' comp. policy infutmation.
I ant an employer that.is protading workerscompensation insurance for nty. employees: Below is the
information. policy and job site
Insurance Company Name: '
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration dale).
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 ofurthis statement may be forwarded to the Office of
a Investigations of the DIA for insurance coverage verification.
l 1 do hereby certfy under the airs andpenalties o
P p ofperjury that the information provided above is true and carred
Sitmature: Date
Phone #:
7cial use only. Do not write in this area, to be completed by city or sown 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
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 insumnee'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 numbers) 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 I N`
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 numberlisted 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
tharmust submit multiple permitAicense 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 .i
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 bum 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. j
The Department's address, telephone and fax number: j
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of investigations "
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Revised 5-26-05Fax # 617-727-7744
www.mass.gov/dia