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Home My WebLink AboutMiscellaneous - Suite 206IN 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance-with the provisions of M.G.L. c. 143, §. 3L, the C• 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 Wiresappointed pursuant to M. 01 c. 166, § 32, an electrical permit shall he issued to the person, fur or corporation stated on the permit application. Such entity shall be responsible for the 4 notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shallbe limited as to the time of ongoing construction. activity, and maybe deemed by-theJnsp.ector-of_W4res abandoned-aad.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 of2010 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 certair-permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically dxtends, 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: /* Note: Reapply for new permit ❑ ermit Extension Act — Permit/Date Closed: Date . � ../,. .vl........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that S— han permission to perform ............4...........................................................t..... wiring in the building of �% ............................................................... 'jr�c/ �f / ........... 7 rl �a,4% C / at.................................................................... , North Andover, Mass. Feet ........ Lic. NoA2.l,ll. I .............. ............... . .. . ...... / ELECTRICAL INSPE Check War s Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 90 ( 9 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 PRINTININK OR TYPEALL INFORMATION) Date: v City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) y p alDavt; It S� Owner or Tenant 7R 2600 i Telephone No. Owner's Address `/S"1 RA/0cu62 OFFI Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Buildin g EAsting Service Amps / Volts New Service Amps / Volts Number of Feeders and. Ampacity Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires d No. of Luminaire Outlets No. of Luminaires INo. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers Heaters KW No. Hydromassage Bathtubs Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters „� 5! ovyc Et5 t J S�rTtNEs No. of Ceil: Susp. (Paddle) Ff No. of Hot Tubs Swimming Pool Above r" grnd. No. of Oil Burners INo. of Gas Burners No. of Air Cond. Tot Tor Heat Pump Number Tons Totals• Space/Area Heating KW Heating Appliances 1 No. of o. of Signs Ballast No. of Motors Total 1 the ollowin table may be waived bYv the Inspector o Wires. IRS No. of Total Transformers KVA Generators KVA ln- rnd. 7 o. o mergency ig g Batte Units FIRE ALARMS INo. of Zones No..of Detection and Iniiiatin Devices Is No. of Alerting Devices No. of Self. -Contained Detection/Alerting Devices Local ❑ Municipal ❑Other Connection CW Security Systems: * _ No. of Devices or Equivalent is Data Wiring: No. of Devices or E uivalent Telecommunications Wiring: No. of Devices or E uivalent Estimated Value of Electrical Work: -J—,04,Attach additional detail if desired, or as required by the Inspector of Wires. tro (When required by municipal policy.) Work to Start bo;✓E 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 9 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete FIRM NAME: /n aw a.P LIC. NO.: __L,;!= Licensee: � r EUC M,�� ,,,[� Signature (If applicable, enter "exempt " in the license number line.) LIC. NO.: Address: /,�F�y�,,� c� ,��y Bus. Tel. No.:A63 idL f9 *Per M.G.L c 147, s. 57-61, security work requires D „ „ Alt. Tel. No.: epartrnent 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 (c Owner/Agent heck one) ❑owner ❑owner's agent Signature Telephone No. PERMIT FEE. S The Commonwealth of Massachusetts Department of Industrial Accidents gt int Office of Investigations `•u 600 Jf ashington Street t1.aa d , Boston, MA 02111 { ' www nxassgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciang/plumbers Applicant Information Piease Print Leibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: . Are you an employer? Check the appropriate box: i. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ i am a:sole proprietor or have hired the sub -contractors listed x partner_ on the attached sheet ship and have no employees These suit -contactors have working for mein any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3.0 I am a homeowner doing officershave exercised their all work right of exemption per MGL myself. [Nonworkers' comp. c. 1.52, § I (4), and we have no insurance required.] t employees. [No workers' comp. insurance required_] Type of project (required): 6. [] New construction 7. Remodeling S. Q Demolition 9. ❑ Building addition 10.Q Electrical repairs or additions I I .Q Plumbing repairs or additions 12.(] Roof repairs 13.7.Other Homeown,u' our me secaon below showing their workers' aompensatiori policy information. t ers who submit this affidavit indicating they am doing all work and then hits outside contractors must submit a new affidavit indicating such. ;Contractors that check this box musrattached an additional sheet showing the aurae of the sub -contractors and their wor�,,rs' comp. policy infomiation. I ant an employer that is pri?Y ing:workers' compensation imurancefor mV employees: Below is the inforpolicy and job site m adon. Insurance Company Name: Policy # or Self=.ins. Lie. #: Expiration Date: Job Site Address: City/State2ip: 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 Si Lure: Date: Phone #: Df,ficial 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): L 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 emp foyers 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 Ficensing agency shall withhold the issuance or renewal of 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 workerscompensation• affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), addresses) 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 i 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 numberlisted below. Self-insured companies should enter their self-insurance license number on the appropriate dine. 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 permittlicense number which wiII be used as a reference number: In addition, an applicant that must submit multiple permiVlicense 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 Investigptions 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. r The Department's address, telephone and fax number: , The Commonweadth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, IviA 42111 TeL # 617-727-4900 Ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7744 www.mass.gov/dia Frorr..KathY Corey Faxlo:603 625 9624 Kelly MUNZCOR-01 KCOREY DATE (MMIDDIYYYY:AM ACORD" CERTIFICATE OF LIABILITY INSURANCE 611 112009 11: 15 (603) 625-9653 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE T OR Kelly Insurance Agency, Inc. ALTER THE ISEF NOT AFFORDED BY THE POLICIES BELOW 80 Canal Street P. O. Box 5700NAIC # Manchester, NH 03108-5700 INSURERS AFFORDING COVERAGE 329 INSURED The Munzing Corporation INSURER A: Merchants Insurance Group 104 12 Patten Road INSURER B: Hartford Underwriters Ins Co Merrimack, NH 03054 INSURER C: INSURER D: DVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY 1 THIS PERIOD CERTIFICATE TED. MAYNOTBENS ISSUED O ING RM�CONDITION OF ANY ESROTHER �TLECT TO WHICH SIONSANDCONDITiONSOfSUCH ANY MAY PETAINEINSURANCEAFORDEEDBYYTHEPOLIICIDESCRIBEDHERESSUBJECTOALTHETERMS,EXCLU POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIDLAJMS-CyEFaTVE POLICY EXPIRATION LIMITS POLICY NUMBER TE MIDDA'YYY OATE 11rID - Y"r Y' 1,000,0( dRKu IIOBN(`F 1 1 EACH OLAIf'F S GENERAL LIABILITY A � rX7 COMMERCIAL GENERAL LIABILITY CLAIMS MADE ® OCCUR LIMIT AUTOMOBILE LIABILITY ANY AUTO ♦ ALL OWNED AUTOS SCHEDULED AUTOS HIREDAUTOS NON -OWNED AUTOS %GE LIABILITY ANY AUTO EXCESS I UMBRELLA LIABILITY OCCUR D CLAIMS MADE 11123/2008 1 1112312009 PERSONAL &ADV MJ1RY $ GENERAL AGGREGATE $ DDnni ic7c- ('OMP/OP AGG $ COMBINEDdtSINGLE LIMIT $ BODILY INJURY $ (Per person) BODILY INJURY $ (Per accident) PROPERTYDAMAGE $ (Per accident) AUTO ONLY - EA ACCIDENT $ OTHER THAN EAACC $ AUTO ONLY: AGG $ EACH OCCURRENCE $ AGGREGATE $ S 1 DEDUCTIBLE RETENTION $ nPOLICY OTH- YYORKERS COMPENSATION •- AND EMPLOYERS•LIABILITY Y/N 6SSOUB000ENS1808 11/12/2008 11/1212009 NT $ 100,000 B .ANY PROPRIETORIPARTNER(EXECUTIVE 100QQQ OFFIGERIMENSER EXCLUDED? a EMPLOYEE $(Mandatory In NH) 500,000 it yesdesmbe under LICY LIMIT $ SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS General certificate subject to policy terms and conditions. Workers Compensation: Steve Munzing is excluded from coverage. Town of North Andover, Building Dept 1600 Osgood St, Bldg 20, Ste 2-36 North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER VMLL ENDEAVORTO MAL10 DAYS WRITTE4 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO So SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORIZED REPRESENTATIVE - - —a nnnn Amnon rnRTanRATION_ All riahts reserved. ACORD 25 (2009101) - '"-" ---- - The ACORD name and logo are registered marks of ACORD V Date.....`. �Z.:.a�...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that �`"�`t"' `< ..... ... `'!'�"�.................... ......................... e has permission to perform ..... . ............. y wiring in the buildirl of...........................a/ y� ....C.......1. �/ . ..... ...`��bNorth Andover, Mass. at ............. ................:...../� .. D Lic. No........�................................................ Fee....... .....�.1. /% ELECTRICAL INSPECTOR Check # a��J U 5205 7 a`yM5pO�0 The Commonwealth of Massachusetts Office Use Only "rr —1r1 Department of Public Safety Permit No, s ^� BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupa.cly, & Fee Checked 3/90 (leave blank) APPLICATION N FOR PERMIT TO PERFORECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Cod 5 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date 5 ^ 0� City or Town of mume U_ 1� ` �' ► (l' ,e— _---.--To the Inspector of Wires: The undersigned applies for a permit to perform th�elelle/ctrical work described below. _�4ocation (Street & Num a ) � n�1'/y ��Gf� (��4 -- Owner or Tenant � �"v `r T ` (�_ cy�f — — Owner's Address 0 CQ Chelmsford, Ma. Is this permit in conjun.tion with E. building permit yes Vno ❑ (Check Appropriate Box) Purpose of Building i (`Z S(" 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 c - Location and Nature of Proposed Electrical WorksC\Y-cu\ Sldky c OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ NO ❑ I haave submitted valid proof of .same to this office. YES ❑ NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE ❑ BOND ❑ OTHER ❑ (Please Specify) Estimated Value of Electrical Work $ r Work to Start Inspection Date Requested: Signed under t 4epenalties of perjury: / _120 C— FIRM NAME 1 ("�A�tk q\'t i(— Licensee W AkQn" Yvt ( 4 `` Signature ins (Expiration Date) Rough Final__ — NO. 7d� LIC. NO. Pi �L Address G`ns ' I V� t� C Y V Y Q �Ci �3 Bus. tel. No.. Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that my signature on this application waives this requirement. Owner Agent (Please checkQne) Telephone No. P'= iMIT FEE $ (Signature of Owner or Agent) TOTAL No. of lighting Outlets No. of Hot Tubs No. of Transformers KVA Above In ❑ ❑ No. of Lighting Fixtures Swimming Pool rnd. grnd Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and TOTAL No. of Ranges No. of Air Conditioners TONS Initiating Devices No. of Sounding Devices HEAT TOTAL TOTAL No. of Disposals No. of Pumps TONS KW No. of Self Contained Detection/Sounding Devices No. of Dishwashers Space/Area Heating KW Municipal ❑ ❑ No. of Dryers HeatingDevices KW Local Connection Other No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. of Hydro Massae Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ NO ❑ I haave submitted valid proof of .same to this office. YES ❑ NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE ❑ BOND ❑ OTHER ❑ (Please Specify) Estimated Value of Electrical Work $ r Work to Start Inspection Date Requested: Signed under t 4epenalties of perjury: / _120 C— FIRM NAME 1 ("�A�tk q\'t i(— Licensee W AkQn" Yvt ( 4 `` Signature ins (Expiration Date) Rough Final__ — NO. 7d� LIC. NO. Pi �L Address G`ns ' I V� t� C Y V Y Q �Ci �3 Bus. tel. No.. Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that my signature on this application waives this requirement. Owner Agent (Please checkQne) Telephone No. P'= iMIT FEE $ (Signature of Owner or Agent) A NORTH ANDOVER BUILDING DEPARTMENT 400 Osgood Street ��'Swc►+u5�� Tel: 978-688-9545 Fax: 978-688-9542 BUSINESS FORM FOR TOWN CLERK DATE: 41:11 y 3 Z 05— NAME: S S Px fV( �-�SSorr�TPS LLC ADDRESS:L 5 / hn odd UP ✓ S ri- - - 1&u& 2-c6 ALi✓I a10 ve v ZONING DISTRICT: TYPE OF BUSINESS: M e do , Cg l BUILDING LAYOUT PROVIDED: YES rNNOS AVAILABLE PARKING SPACES: ZONING BY LAW USAGE: YES NO BUILDING INSPECTOR SIGNATURE Revived 11.5.04 BUSINESS FORM FOR TOWN CLERK Location Aycjuc.-v e S� No. ---19 CP- Date —12 ,U c NORT1 TOWN OF NORTH ANDOVER + i Certificate of Occupancy $ sACMUs Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ v - + Check #JSP l 171 8 3 ��( (�-^-- i Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVAT5 OR DEMOLISH A ONE OR TWO FAMILY DWELLING n� BUILDING PERMIT NUMBER: \ DATE ISSUED: SIGNATURE: Building Commissionerff for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Addr 1.2 Assessors Map and Parcel Number: ,Property G Z ky 6-b 240 7 n "1b `' 7 _ � L/V C� Map Num Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area s Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: - Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2- PROPERTY OWNERSIIIP/AUTHORIZEDAGENT Historic District: Yes No 2.11 Owner pf O 1 Name (Print) Address for Service: lure a Te ephone . Owner of Recor Name Print Address for Service: f Si nature Telephone SE ION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Con ion Supervisor: �lD License Number dress A 3 _ L l r L �p / 4 Expiration Date j Signature VTelephone 3.,,)Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone Wa SECTION 4 - WORKERS COMPENSATION (NtG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi rmit. Signed affidavit Attached Yes ..... No ....... ❑ (✓ p SECTION 5 Description of ro osed Work check all a livable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be}I+`IC7SE;t}NLY Completed by permit a licant '"; " I. Building (a) Building Permit Fee Multiplier 2 Electrical "1T (b) Estimated Total Cost of Construction 3 Plumbing -- Building Permit fee (e) X (b) (� 4 Mechanical HVAC 5 Fire Protection —" 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORUXTION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, C— 6► Ldff--� "moi J Q U'� as Owner/Authorized Agent of subject property ry Hereby authorize { — to act on v alf, in atte s lative to wor a orized by this building permit application. W11ire of Owner Date S CTION 7b OWNE AUTHORIZED AGENT DECLARATION I> J L� o C vti ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief V �- :n— -e tJ P t e c v V ature of Owner/Age t Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1ST 2ND 3 Im SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CBR NEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 172111 Workers' Compensation .insurance Affidavit city Phone # 1 am a homeowner performing all work myself: I am a sole proprietor and have no one worldng in any capacity . I am an em er providing workers' cornpensati for my em working on, this job. Gornoanv name: c /address ►;�. 6 2 5 y Instl ct�_ -PO Y -APolicy# f 1 ! _ ri % <�1 Cotnaamr name: i 6l�S Facto secure ooNe aqe as requiredw� Se and[or once yewe' imprisorirrreot as ass�ai p uuederstand that a copy of tans statement may be I do hereby certify wn *r Me pains and penelffes Print or MC L 152 CW festa t&the ippOWM orairk"Piena i�eSam��.,$l9� Jioe t to the offk&bf tmeeatigabons dune MA -for gage, hw the kobrfl atiarrprovided above its brae aW eorneeb _c ] U-4 y North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be , disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. The debris will be disposed of in: (Location of Facility) Signa a of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector pp 1 ✓1 e i�omvrrca�u�rP,a.�.fi o�✓f/laQaactuaetla "� BOARD OF BUILDING REGULATIONS tense: CONSTRUCTION SUPERVISOR Dumber: CS, 059666 A94rthdate:03/25/1952 Expires: 03/25/2006 Tr. no: 17609 Restricted:- 00.' CLAUDE J BEAUDOIN 200 DEPOT RD h HAMPSTEAD, NH 03841 Acting C mis oner t t n� m m m m YI m is mm ) H Sm CD 'O � O C! Z y CD O C- r C d y �CD CD CD o CLQ "� CD CD CD CD C O H° CD CL O CO) CD i I W.0116'' F n C/), ?— p d fN p � H dp5® t/3 a®� m n O. U=2 n CL C-) m Z • ® �� y p �IM =r CL p m wCD A O N C i/9 N p m m = m p n � i0 p p y!9 ►� w �oCD :e Ca S N C', r...« . tC O S _ CD m ch : b CD 1 ` C d go Co G H N O. of : � S a a H CD CD CA a Ob m d N = n w oCD O O s Ift cn =m3 p W :\ d� T _ CL C') 0 . o =1 e e 10, pPTJrDcn 9 PL oda O w oGv tz F. O 7d a" t � w oGn a' a � C� r d � CD �^ goil 0 " e e 10, ,_3q5? Date ..,71,- ........... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that has permission to perform <_7 plumbing in the buildings s of--ildin ' ..... ................. at....... North Andover, Mass. B Feer... ... Lic. NcO.L'J'9 �km I' w G INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS —�0� •�— 3 Building Location 7S� 0gNb6je& `�, / Owners Name IW -41S M&�f e etrmit 6s. Amount Type of Occupancy New Renovation ri Replacement 13 Plans Submitted Yes. No ❑ (Print or type) n /� I� M plum j_i� +�� Check one: u. Certificate Installing Company Name L�. ElCorp.. Address UI/%L Partner. Busmess Telephone -7 _ Firm/Co. Name of Licensed Plumber: 1`�2[15 /k'1 (!-Uig ►7 e -X Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under PertmitjIssued for this application will be in compliance with all pertinent provisions of the Massac etts tat lum g o e apter 142 of the General Laws. By:'Signarure o ice se um er Type of Plumbing License Title /10 I S p City/Town Mense NumDer— MasterJourneyman (OFFICE APPROVED (oCE USE ONLY M3 113 IfNI 1MMWMMMMMMMMMMMMMWMMWMMM--- IT `B►I B►I ----------W--------.M.- - MMO MM /. --------.M---------------. (Print or type) n /� I� M plum j_i� +�� Check one: u. Certificate Installing Company Name L�. ElCorp.. Address UI/%L Partner. Busmess Telephone -7 _ Firm/Co. Name of Licensed Plumber: 1`�2[15 /k'1 (!-Uig ►7 e -X Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under PertmitjIssued for this application will be in compliance with all pertinent provisions of the Massac etts tat lum g o e apter 142 of the General Laws. By:'Signarure o ice se um er Type of Plumbing License Title /10 I S p City/Town Mense NumDer— MasterJourneyman (OFFICE APPROVED (oCE USE ONLY k r t timet&. , j5l The Commonwea th of Massachusetts Department of Industrial Accidents Office of Investigations 600 Nrashington Street Boston, MA 62111 r I www_nzass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/pinmbers Anoiicant Information Please print Ltcq bb Name (Business/Organization/Individual); �./' �l�✓nhi�� I�' Address: City/State/Zip- one 9/ Are you an employer? Check the appropriate box: I.11 am a employer with Z 4. ❑ 1 am a general contractor and I Type of project (required): employees (full and/or part-time).* have hired the sub -contractors 2.❑ I am.a.sole listed 6. ❑ Now construction . ?• proprietor or partner- on the attached sheet. I ❑ Remodeling ship and have no employees These su}rcontractors have $. ❑Demolition working for me in any capacity, workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its 9. ❑ Building addition required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MOL 10-❑ Electrical repairs or additions I I.9-l�nrbing myself. [No•workers' comp. Q t52, § 1(4), and we have no insurance repairs or additions 12-ElRoofrepairs reuired. t q ] employees. [No work=' 13❑Other camp. insurance required.] "Amy eppiicartt that checks boat # l must also fill out the section below showing their workets' compensation fbnnatiotL policy in t iiameownM who submit this affidavit indicating they are doing all work and then hire outside contractors mustsubmit a new affidavit indiesting 'Contrantors that check this box most attached such. an additional sheer showing. the name of the-b-comrsotom and their workers' comp. pati information. -; I ar an employer that is prour&ng:workers' compensation insuramefor my.. employees: glow is the policy and job site inforrnadon. Insurance Company Policy # or Self -ins. Lic. #: Expiration cr: Job Site Address: 4 5/ �()b\j-.aw `j i -- City/State ip: ✓ (i 1 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 es 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 Investigations of the DIA for insurance coverage verification. Office of I do hereby c fy under/ the pains and penalties of perjury that the infornzadon provided ab ve is true and rowed -- A,/_ /n A /% s . n 1 _2 Official use only. Do not write in this area, to be camel&, --d by city or town officio( City or Town: _ Permit/License # Issuing Atrthority (circle one): 1. Board of Health 2. Bniiding Department 3. City/Town Cierk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information a. nd Instructions � Massachusetts General Laws chapter 152 requires all emp 3 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, assadiation, corporation or other legal entity, or arty two or more of the'foregoing engaged in a joint enterprise, and includirig the legal representatives of a deceased employer, or the receiver ortrvstee of an individual, partnership, association or other legal entity, employing employees. 'However the owner -of a dwelling house having not more than three aparrtrrments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maizrtenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of sucb employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state our- local licensing agency shall withhold the issuance or renewal of a license or permit to operate a baseness or *o construct buildings in the commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insarance'coverage required" Additionally, MGG 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 cva-rtracting authority." Applicants Please fill out the workers'. compensation• affidavit compimtely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) wird 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' cornpensation 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 .app.lication 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 nuaxtber listed below. Self +*+cured c�+mp*�ri shculd err*their self insurance -license number on the•appropriate'line. City or Town Officiais Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit.for yoir 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 v► -ill 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 poiicy'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.officiaily 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 hike 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 InvestiDations 600 Washington Street Boston, MA 02111 TeL # 617-727-4900 text 406 or 1-977-MASSAFE Revised 5-26-05 Fax # 617-727-7744 www.mass.gov/dia Date ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......1. 2� ..... has permission to perform ..... ........................./t.. 7 .......... .. wiring in the building of .......... Ple ... CP4,4^ ................................... 7 ....................... at .... ..........................,,,N,,orn An p_th Andover, Mass. Lic. No. J�M.2.!B ....... ..... . Check 4ECTRICAL INSPECTOR # Commonwealth of Massachusetts Official Use Only �{ Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS 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 15 7 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: / p y City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Andover Sa. �(� 'goo/n r Owner or Tenant O ' Telephone No. wner 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 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 /'i?dpe uaaaovnac aeract u aesirea, or as required by the Inspector of Wires. Estimated Value of El c 'cal Work: (When required by municipal policy.) Work to Start: 9/� p �_ Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C VERAGE: 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 pains an en s of perju that�he information on this application is true and complete. FIRM NAME: (Otl1 �' � LIC. NO.: Licensee:.4 Rei t -e— Signature ;31-1 LIC. NO.: 336Z6 - (If applicable, enter "exempt " in Ih e licensf numb e i (p 3 — Bus. Tel No... Address: Alt. Tel. No.: Ga 3 — Y3 *Per M.G.L c. 147, s. 57-61, security work requires Department o Public Safety "S" License: . 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. $ f �-,ZA 6 ii cif 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 -t__- T_- w. .. yy f Nan a(Business/Organiration/individual):_ /0,oly t C— e e h 'L• -------------- Address:_ C.-2 II Q City/.State/Zip:-/yK Il'o^ Phone #:. K"!L X7`3 % �� 3 Are you an employer? Check the appropriate box: t. ❑ I am a employer with 4, [1I am a general contractor and I Type of project (required): employees (full and/or part-time),* iwgefn.a.sole have hired the sub -contractors 6. ❑ New construction 7• proprietor or partner- listed on the attached sheet. $ Q Remodeling ship and have no employees These sub -contractors have 8. Q Demolition working for .in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its g, Q Building addition required.] 3. ❑ I am a homeowner doing officers have exercised their MGL 10. ❑ Electrical repairs or additions all work right of exemption per I L❑ Plumbing repairs or additions myself. [No•worke'rs' comp, c. 1.52, § 1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.[] Other comp, insurance required.] --rr••-- ••• ��• w��x n muse also nu 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. 4Corttractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers' comp. poly info nsxtion. I ant an employer that is providing:workers' compensation insurancefgr my employees; Below information is the policy and job site Insurance Company Name: ' Policy # or Self -ins. Lie. #: 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. I do hereby cert fy under the pains and penalties of perjury that the information provided above is true and correct Sienattrre: Date. - Phone #: Official use Only. Do not write in this area, to be completed by city or town ofjciaL City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone*: i y 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, notthe 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 numberlisted 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 permittlicense 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 1-8.77-MASSAFE Fax # 617-727-7744 Revised 5 -26 -QS www.mass.gov/dia