HomeMy WebLinkAboutMiscellaneous - 84 BLUEBERRY HILL LANE 4/30/2018cu
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2012 Massachusetts Electrical Code Amendments 527 CM1112.00 § Rule 8: in accordancewith the� provisions of m.G.L. c. 143, . §. 3L, the
permit application fbim to provide notice of installation of wiring sh . all be imiform 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. CT.L c. 166, § 32, an
electrical permit shall be issued to the perso 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.CT.L. c. 143, § 3L.
Pennits shdLb e limited as to the time of -ongoing construction activity� and may b e�deemed_by_ the.Inspector-of-Wires abandoned.and-irry.alid-ifte— .
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
application.
r 240 of th e Acts of 2010 and extended by Sections.74 and 75 of Chapter 23 8 of
and long-term economic recovery and the Permit Extension Act farthers this
-permits -and licenses concerning the.use or development ofreal property. With
eyond its otherwise applicable expiration date, any permit or approval that was
August 15,2008.and extending'through August 15,2012.
Wvule 8 — Permitawe Closed: Note: eapply for new permit -M,
<Permit Extension Act — Permit[Date Closed: 12— en <Z��
C -5
-4-
Date ........
......................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that f�� f ...... S�
41�-:?Ily ...........................
has permission to perform ........................... .........................
wiring in the build ing of ....................................
at ..... �? .... .......................... ... . ..... . orth Andover, Mass.
6r"
Fee ...... —.. Lic. Na, C's .....................
iLiE R12AL INSP R
C h e c k # c --2t2 L--�s --
8231
A
Lommonwealth Of Massachusetts Official Use Only
Department of Fire Services Permit No.
1
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS - F�,trr
[Rev. 1/071
APPLICATION FOR PERMIT TO PERFORM ELECTRICA�NC
All work to be performed in accordance with the Massachusem Electrical Code (MEC), 527 C�MR 12,00V
(PLEASE PMTINR�K OR YYPE ALL LVFORMATION). Date.
City or Town of.- NORTH ANDOVER
13Y this ..To the!:Impect "Wires:
JZtric
w
application the undersigpne givesnoticeof ��Or her �intention to perform the electric work described below.
Location (Street & Number) (9/y, zj,// /-- /I/
Owner or Tenant
Owner's Address
Telephone No./. P;V.,aV-
Is this Permit il . a c onjunction with a bunding permit? Yes L-ij NoT (Check A'ppropriate Box)
Purpose of Bufiding---,�,;X/6- Aw Utility Auth - 'on
ExistingService -P� Amps IZO Zela Olts oruati?
New Service Amps —V OverheadO undgrdE No. of Meters
W volts Overhead 11 Undgrd [I No. of Meters
usuber of reeders and Ainpaci
Location and Nature of Proposed E—lectrical Work:
sed L�miinair�es
�- �ofRec�es
Completion ofthe follom4np, tnhl.- .—, A. JL..,L- I
Of Ceff.-Susp. (Paddle) F
No. of Luminaire Outlets No. of Hot Tu —
bs
No. of Luminaires .2 Swimming Pou!j Abo
No of Receptacle Outlets No. of Oil Burners
b No. of Switches .2 No. of Gas Burners
s
No.of Ringes No. of Air Cond.
fto. of W Hent F N
aste Disposers UMP ... ber Tons
uni'
n 'Lt
Totals.
No D h hers I
No. of Dishwashers Space/Area Heating KW
'is IE
N 0. a. g pph s
o. of Dryers Heating Appliances
WW o
No. of Water No. of
Heaters K.W Si gns Ballai
No. Hydromassage Bathtubs No. of Motors T I otal
OTHER:
ans
0
No. of 0
T4
Transforme�rs A
Generators KVA
LEJ1
FIRE ALARMS We. of Zones
.L,U. U1 "elecuon and
Initiating llo-yjp�
as
No. Of Alerting Devices
7—
No. of S -wContained
Detection/Alerting Deviem
Local Zoux:ecc'piao, 0 Other
KW
Security Systems:*
No. of Devic valent
ts
Data Wiring:
No. of Devices or E uivalent
HP
Wiring:
.1—r-Cummunications
No. of Devices or Equivalent
Attach addition ta if desired, or ay required by the Ins?,ector of Wires.
Estimated Value of Electric I al Work: (When required by municipal policy.)
Work to Stait, Inspections to be requested in accordance with NMC Rule 10, and upon completion.
,INSURANCE COVERAGE: I fnless waived by the owner, no permit for the Peiformance of electrical . work may issue unless
the licensee provides proof of liability insur-ance including "completed operation" coverage or its substantial equivalent The
under -signed certifies that such cove
_ 5We is in force, and has exhibited proof of same to the permit issuing office..
CHECK ONE: INSURANCEE3"' BOND 0 OTHER [] (Specify..)
fperjury, that the informatio
I ceyWfy, under the pains andpenaldes o
FIRM NAMEE: n On this aPplication is true and complete.
LIC. NO.:
Licensee: Signature
(Ifapplicable enter 11 — LIC. NO. -
e ic z
lic
'0�7,.P in th fi -imber line.)
Address: ;Z1 y Bus. Tel. No.:7,?,/
*Per M.G.L c. 147, s. 57 a4d Alt. Tel. No.:ZiL-196
-61, security work requires Department of Public 9afet
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not y "S" License. Lic. No.
required by law. By my signature below, I hereby waive this have the liability insurance coverage normally
requirement I am the (check one) El owner
Owner/Agent owner's- aggent
Signature Telephone No.
cv,
*Any OPPlicant that ts bo mtot I fill Out the section below showing their workwVbompenntion policy inform
� HoMeawne'S Who Submit this affWaVit indiClIting thay RM daring all work and then him -outside contractors must submit a now affidavit
4contra'Mrs that check this box mustattBehed an additional shear showing the name of the sub-cantracton; and thir worken,, indicating suciL
I am an emplOydr thal.isPr�Viding'worken' cOmpensadon iftsurancefor COMP. Policy infamation.
infornsadon. my mW10Yem Below iS the poficy andjgb *e
Insurance Company Nam.
POliCV 9 or Self-ine I ;� 44.
Expiration Date:
Job Site Address:
Attach 2 copy of the vvOrkers' compensation policy d e*cIarzLti0fl Page (showing the policy --------------
Failure to secure covera number and expiration dzte�
.ge as required under section 25A of MGL c. 152 can I
fine up to $1,5()0,00 and/or one-year' - cad to the imPOsition of criminal penaities of a
of up to $250.00 a d Impnsonment, as well as C'V" penalties in the form Of a STOP WORK ORDER arui a fine
. aY against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investi gations of the DIA for 'Ins ct coverage verification.
I do Un thep ins and . at the infiOTUtafion provided
above is &ue and corr=t
Si
Date -
Phone 4. ZVI-
Officiat use Only. Do not Write, in area, M bc c0i"Pleted by city or town vffraW
City or Town: Permit/Lir-ense
Issuing Authority (circle one):
I. Boa rd of Health 2- Building Department 3. C4/Town Clerk 4. Electrical Inspector 5. Plumbing I . nspwtor
6. Other
Phone#.
The Common weauk of MossachUsea
s
Department of Industrial Accidents
OffIce of Investigations
600 lCaskington Street
Boston, M.4 02111
Workerrl COMP www-massgovIdia
ensRtion lmh,ranee AR-idsvvit: Buflders/Contractorgmectriciling/Plumbers
ARRficant Information
Pleue P it Le-vibly
Narlie, (Busi.ncss/O*Tianiza6an/�indivi6ual)'
;Zllesl �0
Address:
City/Stat5/Zip: 11�:4 dI.Pot Phone #- /OYJ--
Are you an employer? Check the appropriate box:
0 1: arn a employer with
4. 1 am IL general contractor and I
a' pro.
Type of Project (required):
T Y;N
-
YlemPlOYM (full and/or part-time).*
have hired the sub-contractDrs
6 -
6. 0 Now construction
w(
F7O
I am.a.soie proprietor or pwtnw-
listed on the attached sheet 1
R
7. [] Remodeling
ship and have no em ioyees
P
working for me n any capaLit�.
nest sW�-contractors have
workers:, comp. insurance.
it
8. Demolition
[No workers" comp. insuran'c
c
5. We are a corporation and it.
9. Building addition
required.)
1 am a homeowner doing
officers have exercised their
10.0 Electrical repairs or additions
all work
mYselE [NO-workirs'comp.
right of exemption per MOL
c. � L5Z § 1(4), and we have no
I Plumbing repairs or additi=
insurance required.) t
employees. [No workers'
12S7 Roof repairs
comp. insurance required_1
13. [1 OtheT
*Any OPPlicant that ts bo mtot I fill Out the section below showing their workwVbompenntion policy inform
� HoMeawne'S Who Submit this affWaVit indiClIting thay RM daring all work and then him -outside contractors must submit a now affidavit
4contra'Mrs that check this box mustattBehed an additional shear showing the name of the sub-cantracton; and thir worken,, indicating suciL
I am an emplOydr thal.isPr�Viding'worken' cOmpensadon iftsurancefor COMP. Policy infamation.
infornsadon. my mW10Yem Below iS the poficy andjgb *e
Insurance Company Nam.
POliCV 9 or Self-ine I ;� 44.
Expiration Date:
Job Site Address:
Attach 2 copy of the vvOrkers' compensation policy d e*cIarzLti0fl Page (showing the policy --------------
Failure to secure covera number and expiration dzte�
.ge as required under section 25A of MGL c. 152 can I
fine up to $1,5()0,00 and/or one-year' - cad to the imPOsition of criminal penaities of a
of up to $250.00 a d Impnsonment, as well as C'V" penalties in the form Of a STOP WORK ORDER arui a fine
. aY against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investi gations of the DIA for 'Ins ct coverage verification.
I do Un thep ins and . at the infiOTUtafion provided
above is &ue and corr=t
Si
Date -
Phone 4. ZVI-
Officiat use Only. Do not Write, in area, M bc c0i"Pleted by city or town vffraW
City or Town: Permit/Lir-ense
Issuing Authority (circle one):
I. Boa rd of Health 2- Building Department 3. C4/Town Clerk 4. Electrical Inspector 5. Plumbing I . nspwtor
6. Other
Phone#.
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide wor'kers' compensation for their employees.
Pursuant to this statute, an mWtopee is defined as "...evwy person in the sez-vic'e of another under any contact ofbire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, asscD-diation, corporation or other legal entity, Or any two or more
of the'foregoing engaged in &joint enter�rise, and including the legal rcp��scntativ'es of a de=ased employer, or the
T=eiver 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 pmoris to do 111&imtenance, construction or i wtirk on such dwelling house
repair
or on the grounds or building appurtmant thereto shall not bemuse of such employment be deemed to be an ernployer.-
MOL chapter 152, §25C(6) also states that "every state or- local ricdnsing agency shall withhold the issuance or
renewal of a license or permit to opemte a lonsmiess or to construct buildings in the commonwealth for any
Applicant who has not produced acceptable evidence.of compliance with the insurance I coverage mquired."
Additionally, MGL chapter 152, §25C(7) stafts -Neither the comrnanwe� nor any of its political subdivisions shall
enter into any contract fur the pmformance of public work until -acceptable evidence of complia
ian= with the insurance
Tequirernents of this chapter have been presented to the contracting authority."
Applicants
Pleasa fill out the workers' compensati on. affidavit compimtely, by checking the boxes that apply to your situation and, if
necessary, supply siib-contractxyr(s) name(s), address(es) Emd phone number(s) along with their cmificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnm-ships (LLP) with no employees other than the
members or partners, are not required to carry workers' cck-rnpensation 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 cotifirmation of insurance coverage.. Allso'be sure to sign, and date the affidavit. The affidavit should
b ei returned to the city, or town fl= the application for the permit or license is being requested, not'the Department of
industrial Accidents. Shodd you have any questions regar-ding the law or if you are reqaired to obtain a workers!
compensation policy, please call the Dtpartrnent at the-nurriber listed below, Self-insured companies should entertheir
Self-insuran6e, licmse Elumbcr on the* appropriate. lim.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. Tlie 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 sum to fill in the permittlicense number which %%-i]I be used as a refercrice number. In addition; an a0plicant
that must submit multiple permit/ficzmse applications in any given year, need only submit one affidavit indicating,c;Mto
policy information (if necessary) and undzr.,"Job Site Address" the applicant should write "all locations in city or
town)." A copy of�ffie affidavit that has becm officially stwnped or marked by the city town may be provided to the
k or
applicant as proof that it valid affidavit is on file for fulturm permits or 116eiises. A now affidavit must be fibed out ek'h
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. t dog license of permit to bum leaves etc.) said person is NOT requiird to complete this affidavit.
7be Office; of Investi.ptions; would like to thank you in advance for your cooperation and should you have any questions,
pie= do not hesitate to give as a cafl.
The Department's address, telephone and fax number.
The Commonwcmlth of Massachusetts
Department of Industrial Accidents
Office of 1mvestiggations
600 Wa&ington Str;--et
I Basion, MA 02111
Tel. 9 617-727-4900 6Xt 406 or 1-977-MASSAFE
R.evised 5-26-05 Fax 4 617-727-7744
www-mass.gov/dia