HomeMy WebLinkAboutMiscellaneous - 89 MARIAN DRIVE 4/30/2018r � Date. AlIV. A. .
TOWN OF NORTH ANDOVER
' PERMIT FOR PLUMBING
49
This certifies that .. ...� ...... e Kt.(Y � �. ... !?+. • . .
has permission to perform ...
plumbing in the buildings of .....lcl.¢ ................
at
North Andover,
. ..�: ;�.... `%f.�:-�I.�+....l�t.!. Mass.
PLUMBING INSPECTOR
Check „"
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town.�1��N,�;' �y MA. Date:—!Y-1 Permit#
Building Location: ///%�/Q/�/!✓�, Owners Name:l"4
'1 1
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
I I New: U Alteration: ❑_ Renovation: K Replacement: ❑ Plans Submitted Yes ❑
No ❑
FIXTURES
DEDICATED
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-SUBBSMT.
BASEMENT
1ST FLOOR
2ND FLOOR EE
3RD FLOOR
4T" FLOOR
ST" FLOOR
6T" FLOOR
7T" FLOOR
8T" FLOOR
f-► / Check One Only Certificate #
Installing Company Name: ' > l�li✓��)-yyl pyi�.,T
S- ❑ Corporation
Address:'f/ 45 City/Town: State: lniq
o
;Firm/Company Pa rship
Business Tel:�0 Li✓ �� Z
Fax:
Name of Licensed Plumber: 2%T /Q "Ovos,�1y2r ,
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No ❑
If you have checked Yes, please indicate the .type of coverage by checking the appropriate box below.
A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter
Massachusetts General Laws, and that my signature on this
142 of the
permit application waives this requirement.
Check One Only
Signature of Owner or Owner s Agent Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or
Knowledge and that all plumbing work and installations performed under
Pertinent provision of the Massachusetts State Plumbing Code and Chao
By
Title
USE
Type of License
❑ ?rite er
Master
❑Journeyman
ad) regarding this application are true and accurate to the best of my
armit issued for this application will be in compliance with all
y of the General Laws.
of Licensed Plumber
License Number: O6 r%z
00 12 Date ..... .......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
j ---
This certifies that ................ ....... k . �FFI!.5
. ......... ..... ... .......... ..
has permission to perform
firing in the building of ................... .................................
at ....... 0r,e�?.e.v ........ 5,= ................. I�orth Andover, Mass.
Fee..IV��-—Lic. No . .. 4�
,73-2-P ..................
: -0 . ..... . . ... .
0v ELEC-MiCAL NspEmR
Check#
-Commonwealth of Massachusetts Official Use only
Department of Fire Services Fpancy
t No.BOARD OF FIRE PREVENTION REGULATIONS and Fee Checked
[Rev. 1/07]
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 ININK OR TYPEALL INFORMATION) Date: ( c
City or Town oh NORTH ANDOVER To the bispector
of Wires:
By this application the undersigned gives otice of his or her intention to perform the electrical work described below.
Location (Street & Number)_ � 1 n 4 A 0
Owner or Tenant Alb/,7 `o` ,
Owner's Address
Telephone No. �? )/ 3%S".,,7.
Is this permit in conjunction with a building permit? Yes ❑ No
❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service/ Amps 201 t yo Volts Overhead g"" Und rd
g ❑ No. of Meters
New Service 2�trU Amps /,kl/ /I, G Volts Overhead ❑ rd Und
g ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
No. of Recessed Luminaires
of Luminaire Outlets
No. of Luminaires
No. of Receptacle Outlets
No. of Switches
No. of Ranges
No. of Waste Disposers
No. of Dishwashers
No. of Dryers
No. of Water
Heaters
rL c cr, 2. aa,&,*,,p Zkz1, fd
the following table may be waived by the
No. of Ceil: Susp. (Paddle) Fans No. of Total
Transformers KVA
No. of Hot Tubs Generators KVA
Swimming Pool rnd e ❑ in- o. o mergency Lig ting
Batte Units
No. of Oil Burners FIRE ALARMS No. of Zones
No. of Gas Burners No. of Detection and
No. of Air Cond. Total Intiatin Devices
Tons No. of Alerting Devices
Heat Pump Number TonsKW No. ofSelf-Container)
T 4 1
Space/Area Heating KW
Heating Appliances KW
KW No. of No. of
Signs Ballasts
No. Hydromassage Bathtubs INo. of Motors Total HP
OTHER:
zal ❑ivlunicipal
Connection 0 Other
:urity Systems:*
No. of Devices or Equivalent
to Wiring: `
No. of Devices or Equivalent
ecommunications —Wiring..
No. of Devices or Eauivalent
flttach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: 2 D p (When required by municipal policy.)
Work to Start:_ A.- o 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 cover a is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME:
�� _ LIC. NO.:
Licensee: d,�,"�L ✓� e e G _Signature
(Ifapplicable, enter "exempt" in a license number line) LIC. NO.: Z, V
Address: � ,/�A ,FI / /t.4 #A- /90��� r Bus. Tel. No.:�7� -
*Per M.G.L c. 147, s. 57-61, seKirity work requires Department of Public Safety "S" License. Alt. 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
Owner/Agent one) ❑owner ❑owner's agent.
Signature Telephone No. PERMIT FEE. $
ELECTRICAL PERMIT NO. INSPECTION
ELECTRICAL INSPECTOR -DOUG SMALL REPORT:
MJGHIONS.
Failed.— [ ] Re -inspection required ($50.00) - [ ]
Z . Sig re - no initials)
Date
2 'GTNAT 'fh7onT r+mr�i.r_
Passed — [ ] Failed — [ .] Re- inspection required ($50.00) -
Inspectors' comments:
3. UNDER..GROUND INSPECTION:
Passed — [ I Failed
Inspectors' comments:
(Inspectors' Signature - no i
P1NSPEcTjON_SFRVjCFLED NATIONAL GRID Failed —comments:
(Inspectors' Signature - no ini
b- •iTc'ITT i-.m�.� - -
Date
Ke -inspection required ($50.00)
Date,
NAME:
Date
Passed — [ ] Failed — [ ] Re -inspection required ($50.00)
Inspectors' comments:
(Inspectors' Signature - no initials) Date
DOOR TAGS ARE TO BE FILLED OYTT AND LEFT ON SITE 7F MHE AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE -INSPECTION OF 550.00 IS TO BE CHARGED.
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
Name (Business/Organization/Individual):
Address: L/ 1v 4, le
/f �0
City/State/Zip:_Phone #: 3 O V C Z
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
elrrployees (full and/or part-time).*
have hired the sub -contractors
2. Ea 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 ate a corporation and its
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself. [No workers' comp.
C. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12. ❑ Roof repairs
13. ❑ Other
r----••• ••• . ,.....— V VA tY l .,Lub< <u,u 1111 our me 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:
Policy # or Self -ins. Lic. #:
`lJob Site Address:
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.
1 do hereby certify under the pains and penal es of perjury that the information provided above is true and correct.
WZWJ�
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
6. Other
1_6
4. Electrical Inspector 5. Plumbing Inspector
Contact Person' Phone #:
u
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 burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. ## 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax ## 617-727-7749
www.mass.gov/dia