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Sroperty Record Card
PnrrPl m •11 N!1(1Q (LM11_!1(lllll It RV.I)Ikt 9 r . ,, ,,,, :« .. AT --#h A . a ..
oration: 9 PERRY STREET
wner Name: BIBEAU, DENNIS L
ELIZABETH S BIBEAU
wner Address: 9 PERRY STREET
City: NORTH ANDOVER State: MA Zip: 01845
eighborhood: 5 - 5 Land Area: 0.10 acres
se Code: 101-SNGL-FAM-RES Total Finished Area: 1230 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 220,700 220,700
Building Value: 75,900 75,900
Land Value: 144,800 144,800
Market Land Value: 144,800
Chapter Land Value:
http://csc-ma.us/PROPAPP/display.do?linkld=1887350&town=NandoverPubAcc 5/17/2012
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Date.:- ... J.:a .......
° t"'° '• TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
z
This certifies that ........................'tr �-
has permission to perform ............................................
wiring in the building of ....� -� '
..............................................
at ...� ... .:!J ? - .... � '............... , North Andover, Mass.
f Fee .. ...... Lic. No. .
E�ecriucu.lrlsre R °
Check #c��%
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Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. 'a, y9
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked�S 1/071
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT WINK OR TYPE ALL INFORMATIONDate:
City or Town of: NORTH ANDOVETo the '3 `� —� �
e InspectoY of Wines:
By this application the undersigned gives notice of his or er intention to perform the electrical work described below.
Location (Street & Number) e M d
Owner or Tenant
e . (O�a -�a6
Owner's Address Telepho _ ,,.
Is this permit in conjunction with a building permit? Yes
❑ No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps j_ /_��Volts Overhead
Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead
❑ Undgrd ❑ No. of Meters
Number of Feeders andAmpacity
Location and Nature of Proposed Electrical Work:
No. of Recessed Luminaires
No. of Luminaire Outlets
No. of Luminaires
--- No. of Receptacle Outlets
f
INo. of Switches
No. of Ranges
of Waste Disposers
No. of Dishwashers
o. of Dryers
o. of Water KW
Heaters
No. Hydromassage Bathtubs
[a
Completion of the
No. of Ceil: Susp. (Paddle) Fans
INo. of Hot Tubs
Swimming Pool a e
No. of Oil Burners
No. of Gas Burners
No. of Air Cond. Ta
Ta
Space/Area Heating KW
Heating Appliances KW
No. of
Ballasts .
No. of Motors Total HP
4,7 Ing table may be waived by the Inspector of Wires.
No. of Total
Transformers KVA
Generators KVA
o. o mergency Ignrnig
FIRE ALARMS No. of Zones
No. of Detection and
Initiatin Devices
No. of Alerting Devices
No. of Self -Contained
Detection/Alertin Devices
Local ❑ Municipal
Connection E] other
Security Systems:
No. of Devices or Equivalent
Data Wiring:
No. of Devices ar Vnnival.-+
No. of Devices or
Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires.
(When required by municipal policy.)
Work to Start 3 -.2 -d --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 coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE
I certify, under thBOND F1 OTHER ❑ (Specify:)
e ains and penaldesperjury, that the information on this application is true and complete.
FIRM NAME: r
I LIC. NO.:
Licensee: � M v $ — Signature d
(If applicable, enter 'exem t " in tl;e li erase nu er line.) LIC. NO.:
Address: p Bus. Tel. No. 9 17�f Z
*Per M.G.L c. 147, s. 57-61, security work requires D Alt. Tel. No.:
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
Signature Telephone No. PERMIT FEE. k2Qj -
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Nlashingion Street
Boston, NSA 02111
t , www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Piumbers
rin itmnt
Name (Business/Organ ization/Individual):
Address:
City/State/Zip._ f '1MuL Phone #:. %�� — ��5� 7t-/2 7
Are you an employer? Check the appropriate
box:
1. ❑ I am a employer with
4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ( 11 am a:sole proprietor or partner_
(`
Iisted on the attached sheet. t
ship and have no employees
These sub -contractors have
working for me .in any capacity.
[No workers' comp, insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
3. ❑ I am a homeowner doing
officers have exercised their
all work
right of exemption per MGL
myself. [No•workirs' comp.
c. 1.52, § I (4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required..]
FAnv wnnlin..M sr.....w.._1._ —1—
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
S. Q Demoiiti.on
9. ❑ Building addition
10. ❑ -Electrical repairs or additions
1 I.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
t hd.V fill out the Semon below showing their workers' compensation policy information.
omeowners who submit this affidavit indicating they are daring all worst and then hire otnside contractors must submit a new affidavit indicating such.
4t:ontractors that check this box must attached an additional sheet showing• the name of the sub -contractors and their worth' temp, po?ic; in �mtssuc
am an employer that is.providing:workerscompensation irisurance for my.
information employees: Below is the policy andjob site
'
Insurance Company Name:
Policy 9 or Self -ins. Lie. #:
Expiration Date:
Job Site
Address—City/state/zip:
Attach a copy of the workers' .comrpeusaiiou 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 farm 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 unde gat nd penalties of perjury that the information provided above is true and correct
Official use only. Do not write in this area, to be completed by. city ortown ociaL
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector
6. Other 5. Plumbing Inspector
Contact Person: Phone #
Information a i1d Instructions
Massachusetts General Laws chapter 152 requires all emp)oyers 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'covemge 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 woric 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. Ifan 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, nottthe 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 Iicense 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 ofthe 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 1-8.77-MA.SSAFE
Revised 5-26-05 Fax # 617-727-77451
www.mass.gov/dia