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HomeMy WebLinkAboutMiscellaneous - 9 ELM STREET 4/30/2018A Date .....�� ..-... Z.. ?-....... �...`.� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...... .1..`.21.14........... �.��.5.. ........................................................... • has permission for gas installation ........,.'v ....................................................... in the buildings of. t �► at .........'........`..:...'.'.......`...:.................................................1 North Andover, Mass. Fee.3 Lic. No. 0 ? GASINSPECTOR Check # 1 O% i, -` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY �%✓—•-�-� II MA DATE ZZ /t PERMIT # 1-1 ! G JOBSITE ADDRESS OWNER'S NAME Z)ee.Scn v1 GOWNER ADDRESS -5A :� c 11 TEd 97R-6 8,§- FAX _ TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL E] RESIDENTIAL CLEARLY NEW: 0 . RENOVATION: E] REPLACEMENT: ® PLANS SUBMITTED: YES F- --Jl NOa APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER I _ DRYER FIREPLACE FRYOLATOR- FURNACE GENERATOR__ GRILLE ----- INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT (^^ OVEN 1 POOL HEATER ROOM/ SPACE HEATER ROOFTOP UNIT TEST LMIT HEATER UNVENTED ROOM HEATER WATER HEATER O HER - - - - ... INSURANCE COVERAGE ,I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES &PNO III IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY1I OTHER TYPE INDEMNITY ® BOND 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 ONLY: OWNER 0 AGENT Eji SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true a urate to the t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli a th in Apr vis' of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. U PLUM BER-GASFITTER NAME /er,r► /V "-e4_J3Y _ LICENSE# I3 SIGNATURE MP MGF El JP © JGF LPGI © CORPORATION ©#� PARTNERSHIP 0#= LLC# COMPANY NAME: t'�tZ' f�}NB�h�s __ !- ADDRESS f _ laC�i2 I 5' i �1v[___ CITY l _ _ t STATE MZIP G s6? -TEL L/0� . t ?�✓ FAX _ JCELL EMA %,V\V O z H U W a ' 4 z ❑ O y❑ W � F- W O� a z w Q W 5 w � � w C0 g a a a U J ' Ei 0 - IL S2 X: w i- LL H °z 0 H U a C�7 U The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 IF www mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 9 Please Print LeAly Name (Business/Organi�zation/Individual): I�`7✓� �� P Nib )�7� C1" l%1 E'JQ % n, Address: % Pete City/State/Zip: �2' 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. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors ?• ❑ Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet. 1 666 ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance 5. El We are a corporation and its 10. ❑Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11. Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. f Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit a new 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 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 requiredunder 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert' n r the in a e It' of perjury that the information provided abov is true,and correct. ZZ , Sienature: �/��/U'1 ���y " hate: O j . / Phone #: 7 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone 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 employeiis 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 maybe 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 Massachv..spats Department of Industrial .Accidents Office ofInvestigations 600 WasWVon. Street Boston, MA. 02111 TQL # 617-727�4900 at 446 or 1-877:MASSAFF, Revised 5-26-05 Fax # 617-727-7749 'cvww.xr.ass,govfclia PLUMBERS AND GASF;I:TTEFtS" I S:.SU::ES::.::THE FOL LOWING 'L I CENS L L,GE:NSED AS A..;MMTER PLUMBE :GLENN M MCCAB .. 1 POOR`ARM ROA[ :DERRY' H 03038-4209 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 ofongoing construction activity, and may be.deemed-by.the-Inspector_of_Wires abandoned.and.invalid.if he—_.. _ or she has determined that the aufhorized 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 23 8 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 puipose by establishing an automatic four-year extension to certain permits and licenses concerning the use of 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. � r i &de 8 — Permit/Date Closed: 0 Permit Extension Act — Permit/Date Closed: 2-3 *** Note: Reapply for new 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance-with the provisions of M.G.L. c. 143, § 3L, the ZY 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 ofongoing construction activity, and may be-deemed_by.the . Inspector-of-Wires abandoned_and-invalid if he—_. or she has determined that the aufhorized 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 puipose 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. 8—Permit/Date Closed: 0 Permit Extension Act—Permit/Date Closed: ** Note: Reapply for new per-itA�k Date .... :.... Z— ..................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING 41-A1E / 15/q Lap--77- Thiscertifies that ............................................................................:.......... ©UTC.�� 4. / /li4ri � � S has permission to perform.............................................�............... .C.�....... wiring in the building of ...... / U;S C) ................................................................ at ................ n.......ZA-1 5i � ......................I .E..L.. .. orI�tNh Andover, vGer.<, Mf a s �Fee. Lic. No............l...........n ...... .. sPc;0 Check # RICAL 3O3 10650 4 �\N, � -C\ - Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. l b6�3-P� Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 2, All Z City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention ty perform the electrical work described below. Location (Street & Numper)_ `% (vh �>� �(/, /� �lv'e 1/t 1/ Owner or Tenant S�, �f o Telephone No. Owner's Address Is this permit in conjuncts n wi�tka building permit? Yes ❑ No E] (Check Appropriate Box) Purpose of Building �tf �llt ti ;rUndgrd uthorization No. Existing Service e7 u Amps d / Volts Overhead ❑ No. of Meters _ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: V. "'S r'-7et;.,ti .,rfl— f p.,..,; .. s.,hl. . 7, ,,,7 i....L,. � tarn No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators IVA No. of Luminaires Swimming Pool Above [j In- ❑ rnd. Md. o. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat PumpNumber Totals: .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 Heaters KW 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: 6th. l P yg vyf-v 7,�c, L) Y %q Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: sv (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 cover 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 and penalties of perjury, that the information on this application is true and complete. FIRMNAME• LIC. NO.: Licensee: 4Z % Signature /Z� LIC. NO.: 7 J(` (Ifapplicable, enter " mpt" in the licens 7berline.) / Bus. Tel. No.• Address: % . �, i/t/o�v� ✓� dl�� Alt. Tel. No.: 7Y/ - 9 3 L fffr *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. 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 a ent. Owner/Agent PERMIT FEE: $ Signature Telephone No. FLEcCTIRIM PELT NO. I NSPECTTONREPCRT: ELECTRICAL INSPECTOR. s x.OUG.II�TSPCTION. Passed []- Failed-[ Re-anspectionrequired($50.00)-j spetorsCom�Inc' meats: ] (Inspectors' Signature ••no fnitiais) Date 2. I'MAL INS) YXWON; Passed - failed — j ] Re -inspection required ($50.00) •- [ r Inspectors' co eats: (Inspectors' Signature - no initials) Date 3. UNDER GROUND INSPECTION: Passed—[ ] mlecl j ] Re-taspection required ($50.00) - j Inspectors' comments; (Inspectors' Signature -• no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF TM AREA. TO BE INSPECTED IS NOT ACCESSIBLE AND A RE INSPECTION OF $50.00 IS TO BE CHARGED. 0 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): A 611`11(4/4 Address: 70 lk J City/State/Zip: n VM� d IP// Phone #: 7V - S_7?' V/32 Are you an employer? Check the appropriate box: 1. ❑I a a employer with 4. El am a general contractor and I ployees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *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. • 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. #: Expiration Date: Job Site Address: 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. Ido hereby cert under the pai sand pen ties of perjury that the information provided above is true and correct. Signature: Date: Z/ P// Z_ Phone #: W/ J-71- z - Y( � 7 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other 11 Contact Person: Phone #: II 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 I Date....... .............. %:...... °`,•`'° "� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .............................. ........ ........ ......... .............. has permission to perform .:.................. ............................................................ wiring in the building of .......................... r.: ................................................ at ................. 6.:-...........:. ....................................... , North Andover, Mass. Fee..- '::........ .... Lic. No.. ...: %::.? ............................................................... Ft w-rRICAT INCPP.0 MR Check # ~ % �- -�9<r, - %- U v f'r r Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Z2lo a Occupancy and Fee Checked S ° =- [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORIKX-1-7-:r=T All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: ,3-- 19-02 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned ives notice of his or her intention to perform the electrical work described below. Location (Street &Number) E� S �MQT M, /"Il' 1��11rp2 �-S�R Owner or Tenant ()q I d ekllm -r L Ly) C, A- P. (.,\,S 3 V Telephone No. Owner's Address C1 C- kY\ ST P -QR T- A% A-4 &d itz, In q _P -t - Is this permit in conjunction with a building permit? Yes a No ❑ (Check Appropriate Box) Purpose of Building effie' e. k R!a, WAS Utility Authorization No. Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters 1-7 Completion of the following table may be waived liv the Inspector of Wires. No. of Recessed Luminaires 10 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 ❑ n- F-1 rnd. rnd. o. o Emergency ig ing Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Number Tons KW No. o Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Munic'pal ❑ Other Connection No. of Dryers HeatingAppliances KW pp 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 elecommunications Wiring: No. of Devices or Equivalent OTHER: .d1 Attach additional detail if desired, or as required by the Inspector of 6Vires. Estimated Value of Electrical Work- Ir ria ; (When required by municipal policy.) ( Work to Start: 3 - as - Q 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 e is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) G -)n t -i -J- c...t .�, i I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: 3-0 LIC. NO.: e 3 c1`�- Licenseei �„ (��. �-f �A-IA Signature LIC. NO.: d- (Ifapplicab e, ente�r -,1 empt" in the license numberr li� Bus. Tel. No..9? gri4- rw`11 Address: e" ISA S't 0AAAE36217 mll'S3 0 t t133- 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: $ Signature Telephone No. V The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' a 600 Washington Street t Boston, MA 02111 5� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): DVA J e Address: (2-f) t yk S CC -.Q City/State/Zip: 9 aA A Fy (Z_� P1 M 5 Phone #0? 1s) Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I ,m ployees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, X1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. Q Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *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: Policy # or Self -ins. Lic. #: Job 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. I do hereby r ' y 4u�er the pains and Sign C of*rjury that the information provided above is true and correct. 51(- (Q)99, Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # . -II-)-o 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 #: