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HomeMy WebLinkAboutMiscellaneous - O'Connor HeightsD i L A a A&_ Date .... . .... ................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,-- , �/Ce \ — S This certifies that .... 9:7/ . ..... j .................................................. has permission to perform ..... 4-41 .0 / /. .................... wiring in the building of ..... ��/ ............ 7 ............................ . ...... at 0 co -�� /�- A— .4 7� ...... ........... . North Andover, Mass. ................................................................... w .... ............. j Fee....... Lic. No. &.7.7 . ..................................................................................... ELECTRICAL INSPECTOR Check# i Commonwealth of Massachusetts Department of Fire Services 'aM , BOARD OF FIRE PREVENTION REGULATIONS fficial Use Only al Permit No. � A 0 apI— I Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 c.MR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date:__j p ? City or Town of. NORTH ANDOVER To the Insp ctor f Wires: 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 PCS Owner's Address ( M Is this permit in conjun tion with a buildipermit? Yes ❑ Purpose of Building p UX C f� G j f - Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: O Telephone No. 4'78- No Z8-No W (Check Appropriate Box) (�\ Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters 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- El rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: I Number ................................................. Tons KW . No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Securityo System : 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 No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wtres. Estimated Value of Plectrical Work: (,UC`� (When required by municipal policy.) Work to Start: U . /� Inspections to be requested in accordance_ with MEC Rule 10, and upon completion. INSURANCE C VE GE: 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the ains and penalties of perjury, that the inform on on this application is true and complete. FIRM NAME- . L LIC. NO.: 9 A Licensee: Signature LTC. NO.: (If applicable, enter "exempt" in the license number line) Bus. Tel. No.. Address: 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. J ❑ 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 M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed ❑' Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass R Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: x Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts F Department of IndustrialAccidents .b. _ I Congress Street, Suite 100 Boston, MA. 02114-2017 www mass.gov/dia Workers, Compensation insurance Affidavit: Builders/Contractors/Electricians/1'14mbers. TO BE FILED WITH THE PERM[TTING AUTHORITY. Please Pxint Le 'bl A ' licant Information Name (Business/Organization/individual): Address: Phone #: Are you an employer? &e k the approprlate box: 10 I am a employer with employees (6111 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.L] I am a homeowner doing all work myself [No workers' comp. insurance required.] t <1 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.t 6. ❑ We are a corporation and its, officers have exercised their right of exemption per MGL c. 152, § 1(4), and We have no employdes. iNo workers' comp. insurance required.] Type ofproject (required); 7. ❑ N&'oonstxuction 8. [] Remodelig 9. ❑ Demolition 10 ❑ Building addition 11.[] Electrical repairs or additions 12. Q pIpmn ng repairs or additions 13•. E] Rb6f repairs 14. [] Other *Any applicant that checks boxVI music aisc uu ULL a 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 checkthis 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 employees, they must provide their workers' comppolicy number. X am an employer that is providing workers' compensation insurance for my employees. Pelow is thepolicy and job site information. Insurance Company 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 requited 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. of peijury that the information provided above is true and correct X do hereby certify under tlaepains and penalties. Date: Signature: Official use only. Do not write in this area, to he 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 t'1 '4 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their enipl6yees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract o€hir'e, 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 receivef'or trustee 6fan individual, partnership, association or other legal entity, employing emplbyees. • 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 b6 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 reg4ted." 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 certificates) 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 IndustrialAccidents. 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 (ifnecessary) and under "Job Site Address" the applicant shouldwrite"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 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-NUSSAFE Fax # 617.727-7749 Revised 02-23-15 wwwmass.gov/dia .., ,��;, s ��•�- OP ID: TD ACORO" �:..� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 09/21/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION- ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT DeSanctis Insurance Agcy, Inc. NAME: 100 Unicorn Park Drive PHONE Fax Woburn, MA 01801 MA No. Extl: AIC No "" "`RID #: JUPIT-1 CUSTOME INSURERS AFFORDING COVERAGE NAIC # INSURED 142 Jupiter Lafayette R Inc. INSURER A:Harleysville Insurance 26182 Sal Lafayette Rd. INSURE RB:Technolo Insurance Company42376 Salisbury, MA 01952 D: E: UVtKAUh5 CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iR R TYPE OF INSURANCE B POLICY PPOLICY EXP OLICY NUMBER MM/DD/YYYY MM/ D/YYYY LIMITS GENERAL LIABILITY A X COMMERCIAL GENERAL LIABILITY SPP00000 CLAIMS -MADE ❑X OCCUR X XCU Coverage X Contract Liab GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- XJFC LOG AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS A X SCHEDULED AUTOS BA76461 P X HIRED AUTOS X NON-OWNEDAUTOS A X UMBRELLA LIAB EXCESS LIAR X OCCUR CLAIMS -MADE PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ CMB00000078286P DEDUCT. $ DEDUCTIBLE 12/23/2015 X RETENTION $ 0 BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (PER ACCIDENT) $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY B ANY IN ECUTIVE Y TWC3442671 OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) MA,ME,NH If yes, describe under DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD Repl ��eme �t of Master Boxes at Four Sites - Foun U r rrr[I I I CIY 9 -UNI KAG I ." 1 own and the Department of Housina at Additional Remarks mun 12/2312014 12/23/2015 EACH OCCURRENCE $ DAMAGE TO RENTFU PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ DEDUCT. $ 12/23/2014 12/23/2015 COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (PER ACCIDENT) $ EACH OCCURRENCE $ 12/23/2014 12/23/2015 AGGREGATE $ 12/23/2014 12/23/2015 E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT S If more space is required) L 1 1 1,000 100 5 1,000 3,000 3,000 1,000 1 1 1 NORTA-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Electrical Inspector ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street Bldg 20 Suite 2035 AUTHO:3PRESENTATIV North Andover, MA 01845 ©1988 009 ACOR TION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD NOTEPAD: HOLDERCODE NORTA-1 I- . ' JUPIT-1 PAGE 2 INSURED'S NAME Jupiter Electric, Inc. OP ID: TD Date 09/21/2015 (DHCD) are listed as Additional Insureds.