The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 87 FRENCH FARM ROAD 4/30/2018, q This certifies that .....� ........�.......'-... ± f! ... �...J�.c . has permission to perform ............................ �� '�� S 11,� �L� .......:.......::....�................................................. wiring in the building �of...... 5,c',,, at ........................................ Pry'.. ...... r..^....... ,`North Andover, Mass. Fee..vz. ............ Lic. No. 1141.................................................................................. Date ...'.z...l.l ............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING ELECTRICAL INSPECTOR Check 1 �� • Commonwealth o/ Maddac4ud4a Official Use Only vi Sery c� cc77 Permit No. `till �—I- Occupancy and Fee Checked .1.leparfinani o�,.tire iced 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 Code2 M$12.00 (PLEASE PRINT IN INK OR TYPE A N) Date: Tq1J1 City or Town of: _M%TI To the Inspecto o fres: By this application the undersigned gi nace his r her intention to perform the elq6trical work described below. Location (Street & Number) — Owner or Tenant Telephone No. - Owner's Address Is this permit in conjunction with a building permit? YesUtility AuthorizaNo ❑ (Check Appropriate Bog) Purpose of Building tion No. Existing Service! Amps VcAD / ayp Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / VoIts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 11(• Qayj \1 t% •E-1 r.,r r4 Y'PY` M, -, v-tr-n nD Is Completion ofthe followinjZ tabre "may be waived by t& Xnsnector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans o. o ota Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool d Above ❑ d. E] grnNo. Bane UnitsEmergency g of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners o. of n InitiatingDevices No. of Ranges Totalo No. of Air Cond. .L No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number ... ons o. o e - ontam Deti"ou/Mel-6112 Devices No. of Dishwashers Space/Area Heating KW municipal Local [IConneccti❑ Other No. of Dryers Heating Appliances KW SecuritySystems:* No. of Devices or Equivalent No. of Water KW Heaters o. o o. o signs Ballasts Data Wiring: - No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP a ecommumcations urmg• No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. ^ Estimated Value I alecalWork: (When required by municipal policy.) Work to Start: IInspectionsto be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C: 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 ge 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 d complete. FIRM NAME: 1 SALIC NO • Licensee: ZpYY1�' Signator LIC. NO.: ?�� L41 A - (If applicabl , enter ` mpt" in the lice a number line.) S Bus. Tel. Address: Alt. Tel. No.:Stli -4 -1 h9 S�� *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. -OWNER'SINSURANCE WAIVER: I am aware that the Licensee does not -have the liability -insurance coverage nonually- - — - — required by law. By my signature below, I hereby waive this requirement. I am the (check one) ne)E] owner ❑ owner's a at' Owner/Agent Signature Telephone No. PERMIT FEE: $ CIX The Commonwealth of Massachusetts IQ Department of Industrial Accidents Office of Investigations UT 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibiy Name (Business/Organization/Individual): 1/, v; n <&10 r t l G. Address: -3301 0- S""4 -e- S0 G City/State/Zip: Le0i Lfr" g Y d c( 3 Phone #: TVI- --72-1- G 'r S f Are you an employer? Che the appropriate box: 1. t� t 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 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 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. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition L0.❑ Electrical repairs or additions 1 L.❑ Plumbing repairs or additions 12. ❑ Roof reps' 13:3-6ther Y 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. #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: c,L/gine rr' CRr� Y�•S"r t i c r_ Gs+mown N Policy # or Self -ins. PC. #: VV(_ So y (o Uj Lf U I i Expiration Date: / ( i i Job Site Address: City/State/Zip:�A' 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 11-Z - f S Phone #: TO Z 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 #: VIVINT SOLAR DEVELOPER LLC PHILIP F ZAMP I TELLA JR (EL) 4931 N 300 W - PROVO UT 84604 PbK Thm D•mo A v AO Pwftrs t • 6LM' ICIAMIEZ4 'z i itSUES INE FOLLOWING WESSE AS tiEWSWERED MAST ALE CTR I C I AN VPV(Mt SOLAR DEVELOPER LLC FWILIP SJUNIELLA JR. 4931 K 300 10 1�0 t ftp' 84604 11141 .A 0T%3 �1fi r. 10 1ft EcolibriumSolar Customer Info Name: Email: Phone: Project Info Identifier: 54841 Street Address Line 1: 87 FRENCH FARM RD Street Address Line 2: City: NORTH ANDOVER State: MA Zip: 01845 Country: United States System Info Module Manufacturer: Trina Solar Module Model: TSM 260-PD05.08 Module Quantity: 45 Array Size (DC watts): 11700.0 Mounting System Manufacturer: Ecolibrium Solar Mounting System Product: EcoX Inverter Manufacturer: SolarEdge Technologies Inverter Model: SE10000A-US (240V) Project Design Variables Module Weight: 43.0 lbs Module Length: 65.0 in Module Width: 37.0 in Basic Wind Speed: 100.0 mph Ground Snow Load: 50.0 psf Seismic: 0.0 Exposure Category: B Importance Factor: II Exposure on Roof: Partially Exposed Topographic Factor: 1.0 Wind Directionality Factor: 0.85 Thermal Factor for Snow Load: 1.2 Lag Bolt Design Load - Upward: 820 Ibf Lag Bolt Design Load - Lateral: 288 Ibf EcoX Design Load - Downward: 722 Ibf EcoX Design Load - Upward: 765 Ibf EcoX Design Load - Downslope: 297 Ibf EcoX Design Load - Lateral: 233 Ibf Module Design Moment — Upward: 3655 in -Ib Module Design Moment — Downward: 3655 in -Ib Effective Wind Area: 20 ft2 Min Nominal Framing Depth: 2.5 in Min Top Chord Specific Gravity: 0.42 ,Plane Calculations (ASCE 7-10): 1 Roof Shape: Gable Roof Type: Composition Shingle Average Roof Height: 15.0 ft Least Horizontal Dimension: 30.0 ft Roof Slope: 34.0 deg Truss Spacing: 16.0 in Snow Load Calculations Edge and Corner Dimension: 3.0 ft Stagger Attachments: Yes Include Snow Guards: No EcolibriumSolar Description Interior Edge Corner Unit Flat Roof Snow Load 42.0 42.0 42.0 psf Slope Factor 0.66 0.66 0.66 psf Roof Snow Load 27.7 27.7 27.7 psf Wind Pressure Calculations Description Interior Edge Corner Unit Net Design Wind Pressure Uplift -20.7 -24.3 -24.3 psf Net Design Wind Pressure Downforce 19.4 19.4 19.4 psf Adjustment Factor for Height and Exposure Category 1.0 1.0 1.0 psf Design Wind Pressure Uplift -20.7 -24.3 -24.3 psf Design Wind Pressure Downforce 19.4 19.4 19.4 psf ASD Load Combinations Description Interior Edge Corner Unit Dead Load 2.6 2.6 2.6 psf Snow Load 27.7 27.7 27.7 psf Downslope: Load Combination 3 14.3 14.3 14.3 psf Down: Load Combination 3 21.2 21.2 21.2 psf Down: Load Combination 5 13.8 13.8 13.8 psf Down: Load Combination 6a 25.2 25.2 25.2 psf Up: Load Combination 7 -11.1 -13.3 -13.3 psf Down Max 25.2 25.2 25.2 psf Spacing Results (Landscape) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 67.3 67.3 67.3 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 64.0 64.0 64.0 in Max Cantilever from Attachment to Perimeter of PV Array 22.4 22.4 22.4 in Spacing Results (Portrait) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 44.6 44.6 44.6 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 32.0 32.0 32.0 in Max Cantilever from Attachment to Perimeter of PV Array 14.9 14.9 14.9 in EcolibriumSolar Layout Skirt Coupling O Clamp Q Bonding Jumper Note: If the total width of a continuous array exceeds 35 ft, break array to allow for thermal expansion and contraction. See Installation Guide for details. Warning: PV Modules may need to be shifted with respect to roof trusses to comply with maximum allowable overhang. EcolibriumSolar 'Roof Weights In Conformance with Solar ABC's Expedited Permit Process Module Quantity: 19 Weight of Modules: 817 lbs Weight of Mounting System: 184 lbs Total Plane Weight: 1001 lbs Total Plane Array Area: 317 ft2 Distributed Weight: 3.15 psf Number of Attachments: 92 Weight per Attachment Point: 11 lbs Plane' Calqulations (ASCE 7-10): 2 Roof Shape: Gable Roof Type: Composition Shingle Average Roof Height: 15.0 ft Least Horizontal Dimension: 30.0 ft Roof Slope: 34.0 deg Truss Spacing: 16.0 in Snow Load Calculations Edge and Corner Dimension: 3.0 ft Stagger Attachments: Yes Include Snow Guards: No EcolibriumSolar Description Interior Edge Corner Unit Flat Roof Snow Load 42.0 42.0 42.0 psf Slope Factor 0.66 0.66 0.66 psf Roof Snow Load 27.7 27.7 27.7 psf Wind Pressure Calculations Description Interior Edge Corner Unit Net Design Wind Pressure Uplift -20.7 -24.3 -24.3 psf Net Design Wind Pressure Downforce 19.4 19.4 19.4 psf Adjustment Factor for Height and Exposure Category 1.0 1.0 1.0 psf Design Wind Pressure Uplift -20.7 -24.3 -24.3 psf Design Wind Pressure Downforce 19.4 19.4 19.4 psf ASD Load Combinations Description Interior Edge Corner Unit Dead Load 2.6 2.6 2.6 psf Snow Load 27.7 27.7 27.7 psf Downslope: Load Combination 3 14.3 14.3 14.3 psf Down: Load Combination 3 21.2 21.2 21.2 psf Down: Load Combination 5 13.8 13.8 13.8 psf Down: Load Combination 6a 25.2 25.2 25.2 psf Up: Load Combination 7 -11.1 -13.3 -13.3 psf Down Max 25.2 25.2 25.2 psf Spacing Results (Landscape) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 67.3 67.3 67.3 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 64.0 64.0 64.0 in Max Cantilever from Attachment to Perimeter of PV Array 22.4 22.4 22.4 in Spacing Results (Portrait) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 44.6 44.6 44.6 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 32.0 32.0 32.0 in Max Cantilever from Attachment to Perimeter of PV Array 14.9 14.9 14.9 in EcolibriumSolar Layout Skirt Coupling O Clamp Q Bonding Jumper Note: If the total width of a continuous array exceeds 35 ft, break array to allow for thermal expansion and contraction. See Installation Guide for details. Warning: PV Modules may need to be shifted with respect to roof trusses to comply with maximum allowable overhang. EcolibriumSolar 'Roof Weights In Conformance with Solar ABC's Expedited Permit Process Module Quantity: 6 Weight of Modules: 258 lbs Weight of Mounting System: 184 lbs Total Plane Weight: 442 lbs Total Plane Array Area: 100 ft2 Distributed Weight: 4.41 psf Number of Attachments: 92 Weight per Attachment Point: 5 lbs Plane'Calculations (ASCE 7-10): 4 Roof Shape: Gable Roof Type: Composition Shingle Average Roof Height: 15.0 ft Least Horizontal Dimension: 30.0 ft Roof Slope: 34.0 deg Truss Spacing: 16.0 in Snow Load Calculations Edge and Corner Dimension: 3.0 ft Stagger Attachments: Yes Include Snow Guards: No EcolibriumSolar Description Interior Edge Corner Unit Flat Roof Snow Load 42.0 42.0 42.0 psf Slope Factor 0.66 0.66 0.66 psf Roof Snow Load 27.7 27.7 27.7 psf Wind Pressure Calculations Description Interior Edge Corner Unit Net Design Wind Pressure Uplift -20.7 -24.3 -24.3 psf Net Design Wind Pressure Downforce 19.4 19.4 19.4 psf Adjustment Factor for Height and Exposure Category 1.0 1.0 1.0 psf Design Wind Pressure Uplift -20.7 -24.3 -24.3 psf Design Wind Pressure Downforce 19.4 19.4 19.4 psf ASD Load Combinations Description Interior Edge Corner Unit Dead Load 2.6 2.6 2.6 psf Snow Load 27.7 27.7 27.7 psf Downslope: Load Combination 3 14.3 14.3 14.3 psf Down: Load Combination 3 21.2 21.2 21.2 psf Down: Load Combination 5 13.8 13.8 13.8 psf Down: Load Combination 6a 25.2 25.2 25.2 psf Up: Load Combination 7 -11.1 -13.3 -13.3 psf Down Max 25.2 25.2 25.2 psf Spacing Results (Landscape) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 67.3 67.3 67.3 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 64.0 64.0 64.0 in Max Cantilever from Attachment to Perimeter of PV Array 22.4 22.4 22.4 in Spacing Results (Portrait) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 44.6 44.6 44.6 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 32.0 32.0 32.0 in Max Cantilever from Attachment to Perimeter of PV Array 14.9 14.9 14.9 in EcolibriumSolar Layout Skirt r� Coupling O Clamp Q Bonding Jumper Note: If the total width of a continuous array exceeds 35 ft, break array to allow for thermal expansion and contraction. See Installation Guide for details. Warning: PV Modules may need to be shifted with respect to roof trusses to comply with maximum allowable overhang. EcolibriumSolar Roof Weights In Conformance with Solar ABC's Expedited Permit Process Module Quantity: 12 Weight of Modules: 516 lbs Weight of Mounting System: 184 lbs Total Plane Weight: 700 lbs Total Plane Array Area: 200 ft2 Distributed Weight: 3.49 psf Number of Attachments: 92 Weight per Attachment Point: 8 lbs Plane'Calculations (ASCE 7-10): 3 Roof Shape: Gable Roof Type: Composition Shingle Average Roof Height: 15.0 ft Least Horizontal Dimension: 30.0 ft Roof Slope: 16.0 deg Truss Spacing: 16.0 in Snow Load Calculations Edge and Corner Dimension: 3.0 ft Stagger Attachments: Yes Include Snow Guards: No EcolibriumSolar Description Interior Edge Corner Unit Flat Roof Snow Load 42.0 42.0 42.0 psf Slope Factor 0.99 0.99 0.99 psf Roof Snow Load 41.6 41.6 41.6 psf Wind Pressure Calculations Description Interior Edge Corner Unit Net Design Wind Pressure Uplift -19.4 -31.9 -47.9 psf Net Design Wind Pressure Downforce 11.4 11.4 11.4 psf Adjustment Factor for Height and Exposure Category 1.0 1.0 1.0 psf Design Wind Pressure Uplift -19.4 -31.9 -47.9 psf Design Wind Pressure Downforce 16.0 16.0 16.0 psf ASD Load Combinations Description Interior Edge Corner Unit Dead Load 2.6 2.6 2.6 psf Snow Load 41.6 41.6 41.6 psf Downslope: Load Combination 3 11.7 11.7 11.7 psf Down: Load Combination 3 40.9 40.9 40.9 psf Down: Load Combination 5 12.1 12.1 12.1 psf Down: Load Combination 6a 38.5 38.5 38.5 psf Up: Load Combination 7 -10.2 -17.7 -27.3 psf Down Max 40.9 40.9 40.9 psf Spacing Results (Landscape) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 52.8 52.8 52.8 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 48.0 48.0 48.0 in Max Cantilever from Attachment to Perimeter of PV Array 17.6 17.6 17.6 in Spacing Results (Portrait) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 39.1 39.1 39.1 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 32.0 32.0 32.0 in Max Cantilever from Attachment to Perimeter of PV Array 13.0 13.0 13.0 in EcolibriumSolar Layout Skirt Coupling O Clamp Q Bonding Jumper Note: If the total width of a continuous array exceeds 35 ft, break array to allow for thermal expansion and contraction. See Installation Guide for details. Warning: PV Modules may need to be shifted with respect to roof trusses to comply with maximum allowable overhang. EcolibriumSolar Roof Weights In Conformance with Solar ABC's Expedited Permit Process Module Quantity: 8 Weight of Modules: 344 lbs Weight of Mounting System: 184 lbs Total Plane Weight: 528 lbs Total Plane Array Area: 134 ft2 Distributed Weight: 3.95 psf Number of Attachments: 92 Weight per Attachment Point: 6 lbs EcolibriumSolar Bill Of Materials Part Name Quantity ECO -001_101 EcoX Clamp Assembly 92 ECO -001_102 EcoX Coupling Assembly 65 ECO -001_105B EcoX Landscape Skirt Kit 8 ECO -001-105A EcoX Portrait Skirt Kit 6 ECO -001_103 EcoX Composition Attachment Kit 92 ECO -001_116 EcoX Flat -Tile Flashing 0 ECO -001_117 EcoX S -Tile Flashing 0 ECO -001_118 EcoX W -Tile Flashing 0 ECO -001_363 EcoX Lower Support - Tile 0 ECO -001_109 EcoX Electrical Assembly (optional) 4 ECO -001_106 EcoX Bonding Jumper Assembly 12 ECO -001_104 EcoX Inverter Bracket Assembly 0 ECO -001338 EcoX Connector Bracket 0 ECO_001-359 EcoX Lower Support - Low Slope 0 A 00 D i 'm cn 0 cz 0{ctlo N T �1 zzQ 000 N T i m z zoCo o o 0 N rn ODD N m �J G 0 0 O D 3 O O Omo C moo m T i - - - - - - - D I El I � I I I I V I ` I O O IT\ j I O I O O I D z I I � O o� C° I I < 0` rn =1 On z0 0z I x D v I I m Cl) L - - - - - - - - - — n z 0 F9 - 1 Cn__x0)00 I. m z `Qmz p� -' < C? m mr <�c� �0 C:) (nV' � m 3pD m-zz mo Ln O -< cn zKom Ommz >1'D C m ZO n Z �D Z N =z Z m z Co z to INSTALLER: VI INT SOLAR O O ""O(/�;. i Westwater Residence INSTALLER NUM BER: 1.877.404.4129dmwon�] PV 1.0 3 �^ M -i , m SITEm u O er"t' � �! 1 11. �l 87 FRENCH FAANDOVERRM MA LICENSE: MAHIC 170848 PLAN NORTH 01845 UTILITY ACCOUNT NUMBER: 16295-60006 DRAWN BY: CC AR 4683275 Last Modified: 10/27/2015 4 0 9 7u z�< 100 m 3(1) O x O w in 02 (p C ) .n. N W 0 7 A O O Cn = 3 z W c 5 CD A m { C N K Co z O m z m O O 0 0 0 o O 1 O 11 CA w 3 CD 0 a ^ n (UD � 0 7 O 0 (Ai NL D < o-4 o� fll m O (n N m II U) p OA C Z _ O m0 O C/)u TI m m -0 r m� o0 0 D m m Z m m u C 2 z= INSTALLER: VIVINT SOLAR Q Q n Westwater Residence m ^ ROOF m m INSTALLER NUMBER: 1.877.404.4129 MA LICENSE: MAHIC 170848 �I�n1 ,(� 1 I O u v u u �i A�1 r // a Cr 87 FRENCH FARM RD A PLAN NORTH ANDOVER, MA DRAWN BY: CC AR 4683275 Last Modified: 10/27/2015 101845 6295 UTILITY ACCOUNT NUMBER: 16295 60006 • -0 C) r° C)n m r -D OZ o O -� 0O o ° C + � 0 C m D m r O = m m _ �D �� C)K O�� Z �z o � mm � 0( 0 o0 O >> c D OC Z mjn� D G w D Z cg0m 0 K 0r o C7 oo0 C -0 -0 '� r D m� cn� O m m n K 0 m 0 D 0 o � m C G) o_0 -u >� ° D D —I r m = + D r m m Z m CIL)) � \ m Z r m 0 < i D O � Z nom{ D rn m m 0 C �Cl) K� O'�;o mz� Q � c *� Z O m to -0 O D D n m . z Xm mZ K Z I� Li W " G) � N H -0— ;u Z mm N Cn D O r D p D � 0C/) 5-1D n Z O D O K Kmn� m D -I < 17Z� -uo�� r < r— m D F n D m p Z> n 0 c�X0� C O o m p F M K Z N x. 00 K � N 3, W mD Z C 2 D= INSTALLER: VIVINT SOLAR o O �%��%�� Westwater Residence INSTALLER NUMBER: 1.877.404.4129 PV 3.0 m m MOUNT. m m v v � I' Lfsole [ice i 87 FRENCH FARM RD MA LICENSE: MAHIC 170848 s DETAILS NORTH ANDOVER, MA 01845 UTILITY ACCOUNT NUMBER: 16295-60006 DRAWN BY: CC I AR 4683275 Last Modified: 10/27/2015 wM1lllllll � N n Immmeffiffil M 0 mall Z z z z m N N N N O d N m 0 fD 0 ao rn 01 00 rn D D D D D G) G) G) G) G) 00G) G) G) f� m avow fA <oxD o(n D m0 x -f N Z z 3 x 3 x °� s= N= F,LA(A-0 o 00 o vovc°i CD CD D r 3� ' ' yno< v� 3 �gm ' �— sg�(od in P D=; j .� ."O 70 < r ayo _»n O O C3 -o BL CD CD w BL f a=Q Z aCd ocm o Fm <D CD C7 N Q CCN ,Dal F m o >� N 0@ � x o �. 3 �GZ1�0 pm 0 o C 50 (a 3 CD 0 OOOc a z cn cn o N U3 o � O � �, � 0 �„ m -i T C B CD N U� mQrn rn 3 m N°> a �0 Nip 4,w Ln >CA0 Gip D < < < m �m c D m v,00 ° X01 �n a 0 0 0 Z< ° r^ CCm C � in 0 m B B B n L L H OV IL B B wM1lllllll � N n Immmeffiffil M 0 mall Z z z z m N N N N O d N m 0 fD 0 ao rn 01 00 rn D D D D D G) G) G) G) G) 00G) G) G) f� m avow fA <oxD o(n D m0 x -f N Z z 3 x 3 x °� s= N= r m�n3;� O o vovc°i CD CD D r 3� C yno< 3 3 �gm �— sg�(od in C' 0 U) D=; j n r ayo _»n O O C3 -o N CD CD w f a=Q Z aCd ocm D <D CD C7 N Q CCN ,Dal F m o >� N 0@ � x o �. 3 D�3� n c K�o x. 0 o C 50 (a 3 CD 0 T1 v x z cn cn o N U3 o � O � �, � 0 °C W� rnmT �� CD N U� mQrn VDv o m U1�� 3 m N°> a �0 Nip 4,w Ln >CA0 Gip D �m c D m v,00 ° X01 �n a p g N m �—0 AX D 000 Z X o p=oN� m0�� RcZ- 0 Z 0 z 0 0 D 0 n Z ITmn >;0 m O D « O 0 ri o 0 mC,Kc7.➢c7 U) o 0��(n �o0K-0°DD= Canmm CD 22m m m 3caQ o m o m< n c c Cn v o F L c to 1 O M o 0 3 m� ED 3 d (D � l7 <� (D .o x g C X r.. (D N N O C O O - 06 (n O��T CD O j � �.0 C C 3. 0 �CD �vo CD N CD .C.. N CD Co � Cn CD CD Cn cn '0 N 5, W tb W (O W A N to :D �O)�O V7 ODO NCItNOO ONA V 0 +oDmoo 0> C,0 ivLn < D< D o o D< 2 (7 0 7 a c � r« CD N CL ID 0 Rr Q � C n 0 O 1 d Cn C 0 S O CD N Q 1_ CD z c= D= INSTALLER: IVINTNUMBER: :1.87 NJG V GIJ L1 e solar Westwater Residence OLAR Kim 3 -LINE m m INSTALLER NUMBER: 1.877.404.4129 87 FRENCH FARM RD E 1.0 m DIAGRAM MA LICENSE: MAHIC 170848 A NORTH ANDOVER, MA 01845 DRAWN BY: CC AR 4663275 Last Modified: 10/27/2015 UTILITY ACCOUNT NUMBER: 16295-60006 o A 0 0 00 D O o Gi3Nm T N C7 fn o 0) x C C7 (n O -4 o Z z i Z SAA m O � Z r ;x TI 3 0 K 00) rf1 N (d 0 A — W... Tk 61 ? v W K�0 00rn� oho m -1m min r_.O °--im fA�i O ,AW -i Z W 0 Z C m Z INSTALLER: VII VINT SOLAR o o Jf Westwater Residence INSTALLER NUMBER: 1.877.404.4129 DESIGN mm m , �/��]�� I 1� PV 4.0 LOGIC MA LICENSE: MAHIC 170848 v v O i 87 FRENCH FARM RD NORTH ANDOVER, MA 01845 DRAWN BY: CC AR 4683275 Last Modified: 10/27/2015 UTILITY ACCOUNT NUMBER: 16295-60006 Date ....'..'Z..�.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING f �� This certifies that ...........j�— ........................................(..�........................................ has permission to perform ....i P..!�G......... '.c>C...................................... wiring in the building of.,...,,. ?. --•� �' '�.............................................................. r.............a( ! (�' �' -,!�. ", '4 1„��1..... `� ....�', North Andover, Mass. Fee..... 55............. Lic. N2.14.19 .......................... E...LECTRIC...........A.L........ C....TOR........................... 'I"N"S, Check # Official Use Only Commonwealth of Massachusetts Permit No. Department of Fire Services --r Occupancy and Fee Checked ,M BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C), 52 CMR 12.00 (PLEASE PRINT INMK OR TYPE ALL INFORMATION) Date: 3 Z3 b City or Town of: NORTH ANDOVER To the Inspector ofWires: 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 J -A 44, iia bS-FW �"-, Telephone NA Pg - Owner's Address 5� Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Z Amps I -to /Z40 Volts Overhead ❑ Undgrd No. of Meters l' New Service Zoo Amps 1 Volts Overhead ❑ Undgrd No. of Meters > eJ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Z2 (k Cmmnlptinn f)f the fr llowina 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 AboveIn- Swimming Pool rnd. ❑ rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection andInitiating No. of Switches No. of Gas Burners Devices No. of Ranges Tot No. of Air Cond. Tons No. of Alerting Devices Heat Pump I KW No. of Self -Contained No. of Waste Disposers Totals: I' ....................... Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal ❑Other Connection No. of Dryers 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: _r rrh...... R, Attach additional detail if desirea, or as required by ine !nbPecwr Uj Estimated ValIc Electrica- Work: (When required by municipal policy.) Work to Start:l (0 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCEVERA E: 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: INSURANCEBOND ❑ OTHER ❑ (Specify:) I certify, under th pains rend en Ities of perjury, that the information on this application is true and complete. f� FIRM NA E:. (' Cf�ll LTC. No -:214-1 l Licensee: r QCT lJ Signature LTC. NO.: (If applicable, enter" empt" in t e license number line. l 1 n Bus. Tel. No.. Address: _6 A�-1C 3 4s1� Cis-! ui to -cm , P4 a1 �O 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: $ 5 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: Trench Inspection Pass EN Failed IN Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPE ION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massa. chusetts z Department oflndustrialAccidents I Congress Street, Suite 100 t Boston, MA 02114-2017 Name www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Address: �0 1-k L lkUL L=Q City/State/Zip: W - � m 1 �� f) LAA. Phone #: �v Are you an employer? Check the appropriate box: 1. I am.a employer with _employees (full and/or part-time).* 2 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.FJ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6.FJ 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): 7. ❑ New construction 8. Remodeling 9. ❑ Demolition 10 [] Building addition 11.❑ Electrical repairs or additions 12. Plumbing repairs or additions 13. Roof repairs 14.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 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 state whether or not those entities have employees. If the sub -contractors have employ ees,1hey must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: 'T1 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 required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do h erebyywrztify ftM the pains and penalties ofpeijury that the information provided above, is true end correct. ((- Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # :; ; 12311-6 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 fon• 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 bum 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-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia \ Q ¥ ' -v m: 3 u bLAJLIN ? �«. u * > . 00 2. m 2 �: &&Z & @ » » Ate: �. R«< a : »4 �:?P 2� ƒ } < NORTH ANDOVER BUILDING DEPARTMENT 1600 Osgood Street North Andover Tel: 978-688-9545 Fax: 978-688-9542 .BUSINESS FORM FOR TOWN CLERK DATE: DAME: 4 2 lqh) f2 rp X21 T = r .ADDRESS: F%E//�Cl� ZONINGDISTRICT: TYPE OFBUSINESS: i11,crX--. BUILDING LAYOUT PROVIDED: YES AVAILABLE PARKING SPACES: .ZONING BYLAW USAGE: _ YESd9O 1 BUILDING INSPECTOR SIGNATURE BUSINESS FORM FORMWN CLERK qi r Date ... �^ .....o......... . �.<............ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...................- � � /• � ........../ �................................................. ..................... has permission to perform ............. /Z...... t .. x1...... ` ............ wiring in the building of.......� �'.=...l..t.r.. 1... .I ........................................... at ......S--'7. !............................... � !/, Neth Andover-7Mass. /f Fee .... ��.-� . Lic. No.. 3 /� t r J ...:........................ ... .....1.:....:-�...... ECTRICAL INSPECTGR Check # r i `U i Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. y z Occupancy and Fee Checked aM BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] eaveblank 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 TYPEALL )7FORMATIO.IV) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires.- By ires.By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) i —�'� [ � c4A Owner or Tenant �'�a/-S., s ��j ��jr : (,J�.T�i-2_ Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 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: I su 6 Op '`� � P< 1 T c�J Completion of the following table maybe 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- F1o. rnd. rnd. o mergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches r 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 ❑ 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 Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of 6Vires. Estimated Value of Electrical Work: (When required by municipal policy.) f 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 y 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 thepains andpenalties ofperjury, that the information o zis application is true and complete. FIRM NAME:. i p; 1.-- i J LIC. NO.:6? 3' 9 Licensee: 1a',cl 1,:, 0 Signatur — LIC. NO.2. (If applicable, enter "exempt" in the license number line) Bus. Tel. No.. 24, 49f Address: Alt. Tel. No.• *Per M.G.L c. 147, s. 57-61, security work requires Department o blic 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. $ S,5 ❑ 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: Trench Inspection Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass IN Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH CTION: Pass • Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: PassF 'led e -Inspection Required ($.) El Inspectors Comments: ��- ale-_3/ 4 ,tel Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts 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): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. F1 New construction ` employees (full and/or part-time).* have hired the sub -contractors 7• ❑ Remodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑ Building addition [No workers' comp. insurance required.] officers have exercised their 10.❑Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.E] Roof repairs insurance required.] t employees. [No workers' 1311 Other comp. insurance required.] *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 Lire doing all work and then hire outside contractors must submit anew 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. Insurance Company Name:. Policy # or Self -ins. Lic. #:. Job Site Expiration Date:. 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 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. X do hereby cert under the pains and penalties of perjury Aat the information provided above is true and correct Signature: 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-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 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 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. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial .Accidents Office of Investigations 600 Washington. Street Boston, MA 02111 Tel, # 617-727_4900 ext 406 or 1-877rMASSAFE Revised 5-26-05 Fax #a` 617-727-7749 w�v�v.>t'nass,govldxa b r Date . 4-! t��..`%....... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING I j This certifies that ..... ......:...:......:.:?...........-t7..L.:............................................... has permission to perform ...... ................. plumbing in the buildings of ....... at ...... ...... ......: P.,...:--.. -� -f.\In°.. .......�... c...:..., North Andover, Mass. Fee ....... L�... Lic. No. '. . �rJi.Y... ..► ...................................................................... I PLUMBING INSPECTOR Check # 77/0 N i f �\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of •rny Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chap er 142 of the General Laws. PLUMBER NAME SIEPttE►J c GALINSKY SIGNATURE LIC #—I D3ti J6 MP p' JP ❑ CORPORATION [ # 3 Iq b PARTNERSHIP ❑ # L # COMPANYNAME 6AL40SKY PL0M0jAJ1; v- RIFATIPC� ADDRESS: P.O. GGX 1-7011 CITY NI -.1riz ILL STATE rA•A- ZI.P 01B31 EMAIL www. mrplombel•W1, covet TEL q7V` 37`i- l i+(3 CELL •505-"50q - 5' 90H FAX C05-5,21-- 9 CITY D MA. DATE 1114 PERMIT N JOBSITE ADDRESS ( (' ('LOAC,� t; -fes A J . OWNER'S NAME B (h y% Wo %-r Wim' POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL ❑ PRINT NEW: ❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ CLEARLY FIXTURES Z FLOOR- BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIUSAND SYS 4 DEDICATED GREASE SYS DEDICATD GRAY WATER SYS _ DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK j LAVATORY ROOF DRAIN I z 3 SHOWER STALL I (n SERVICE/ MOP SINK TOILET I I I URINAL I 1 WASHING MACHINE CONNECTION I WATER HEATER ALL TYPES WATER PIPING OTHER I I INSURANCE COVERAGE: have a current liabifitv insurance policy or its substantial equivalent which, meets the requirements of MGL Ch. 142. Yes ),No ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Z - OTHER TYPE OF INDEMNITY ❑ BOND [I OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE BOX ONLY: OWNER E]AGENT E:1Si nature of Owner or Owner's Agent q I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of •rny Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chap er 142 of the General Laws. PLUMBER NAME SIEPttE►J c GALINSKY SIGNATURE LIC #—I D3ti J6 MP p' JP ❑ CORPORATION [ # 3 Iq b PARTNERSHIP ❑ # L # COMPANYNAME 6AL40SKY PL0M0jAJ1; v- RIFATIPC� ADDRESS: P.O. GGX 1-7011 CITY NI -.1riz ILL STATE rA•A- ZI.P 01B31 EMAIL www. mrplombel•W1, covet TEL q7V` 37`i- l i+(3 CELL •505-"50q - 5' 90H FAX C05-5,21-- 7� O c x r 7 G� z DO r� 0 z z O r Ln m F9 co— G7 r r z o C m Z DO r z �* 0 0 �7 N cn ❑CD c O z Elo h Y � � z r� n y O z z 0 y k� S113Sf1HobSSvW =iO H1ld3MNOWWOO 'd•