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HomeMy WebLinkAboutWiring Permit (s) - Correspondence - 1160 GREAT POND ROAD 9/17/2014 f Date ;, 7 ............... 4 �,.': �c'.:•�°oL TOWN OF NORTH ANDOVER 0 9 PERMIT FOR WIRING HUg� 4 = This certifies that °m �. .... g has permission to perform r r � . ............................... ... wiring in the building of...,... �. ................. t .............North Andover,Mass. Fee.....a 'p "A Lic.No. .� � � ... ELECTRICAL INSPECTOR Check# k �w, Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [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 CMR 12.00 (PLEASE PRNTININK OR TYTE ALL INFORMATION) Date: Z— 6Z City or Town of: NORTH ANDOVEJ R 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) /I Owner or Tenant (11"(Z'Cks Telephone No. Owner's Address Y 4-0, Is this permit in conjunction with a building permit? Yes No F] (Check Appropriate Box) Purpose of Building )Z 0 n ��v, q 0 Utility Authorization No. Existing Service Amps Volts Overhead[—] Undgrd[I No.of Meters New Service Amps Volts Overhead El Undgrd [I No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luirninaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above n In- E] 1N 0'of Emergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FM ALARMS iNo. of Zones of Detection and No.of Switches No.of Gas]Burners No. InitiatinR Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons Heat Pump I.Ng!gber I Tons I KW No.of Self-Contained No.of Waste Disposers Totals: I .............. ............... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑[I Municipal F] Other Connection Security Systems.* vs ems. , No.of Dryers Heating Appliances KWSec No.of Devices orI ulvalert'i-," No.of Water No.of No.of Data Wiring: �p Heaters KW Signs Ballasts No.of Devices or Equivalent No.Hydromassage)3athtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE less 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 -[J BOND [I OTHER El (Specify:) I certify, under the pains and penalties ofteijury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: ( /",")/ /3 ,,I �) 7�1 ,,,�c�r e( Signature/ LIC.NO.:. (If applicable,enter "exempt"in the license nnmber 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)D owner [:1 owner's agent. Owner/Agent I PERMIT FEE: $ Signature a Telephone No. -3 70 X � -�/ F 1❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c. 143,§3L,the 1 permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed r 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 persoh,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 Sm—tion 173 of Chanter 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,far 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 Q Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Q Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL GH INSPECTION: Pass 3 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass F ed Q Re-Inspection Required($.) ❑ Inspectors Comments: % z''s"� Vic_ c .•� Inspectors Signature: Date: FINAL INSPECTION: Pass Failed Q Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth o,f Massachusetts . Deparim nt of lndt?strigl Accide is Office of Investigations 6#0 Waskingtorz Street Boston,.MA 02111 -www.rnassgov/ciia Workexs' Compensation Insurance Affidavit:$uffders/Conl rcaci-ors/FIectxzcxans/Plitmber.m ;AuyReant"Worrnai.on Please Print Legibly 'Name,(Busianess/organization&dividuat) "�� ' C � s��'�� r'""`"� I � �; Address: Ph #: City/State/Zip. i� .... �k.a�� w.. ,,.-. d�J ona �' �a ,. Are you ant employer?Cheep the appropriate box: Type of project(required LEI I am a employer with 4. ❑ x am a general contractor and I 6. El NOW construction employees(full and/or part time).' have hired.tho sub-contractors 2—[ I am a sole proprietor or partner- listed.on the attached sheet. 7• R emodeling ship and'lzave no.employees. These sub-contractors have 8. C(Demolition working .for me in any capacity, workers' comp.insurance, g, Building addition [No workers' comp.insurance S. ❑ We are a corporagon and its ME.I Electrical repairs or additions required.] officers have exercised.their 3.❑ I am a homeowner Ring all work right of exemption per MGL I LEI Plumbingrepairs or additions myself.[No workers,comp. c.152,§1(4),and we have no 12,Q1;'..00frepaixs insurancere ixed.]i employees.[No workers, comp,insurance required.] aEl Other xAny applicantthat checks box#1 must also fill outtho section below showing their workers'compensationpolicy information. t'Homeowners who submit!his affidavit indicating they a'ro doing all worXand then hire outside contractors must submit a new affidavit indicating such. lContractors that cheakthis box must attached an additional sheet showing the name o£the sub-contraotors and their workers'comp.policy information. X am are employer that isproviffing worrkers'compensatlon insuranee formy employees Below is thepoliey anrijoh site infoxmmadon. Instuance Company Name:. policy#or Self ins.Lic.ff: Expiration.Dato: . lob Site Address: City/State/Zip: Attach a copy of the workers'compensationp olicy declaration page(showing the policy number and expiration date). Failure to secure coverage as requixed.under Section 25A ofMCL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500,o0 and/ox one"year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER.and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be foxwardedto the Office of lavestigations of the DIA.for insurance coverage verification. X do hereb cent' u e tlx�p ' p f p y y f provided above is true and correct. y r � � awns anrZ enarties a er'arR treat flee information rovacie Si�niature• � Date, Phone# Y official use artly. Do not write in this area.,to be completed by city or town official; City or Town: Permit/License# Issuing A.`u-thority(circle one): 1.Board of Health 2.Building Department 3.City/T'owo Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone 0: commonUvealth of Mas �usetts Division of Registrati Board of'Electri _ I WILLIAM D B - 28-1 MO 1 o. FREMON - tt Journeyma lec �¢ 14018=B 07/31/2013 sve 006754 License No. Expiration Date. Serial No. ' * <COMMONWEALTH OF MASSACHUSETTS ® ® ® tea ® BOAF>iD�F I IS$UES.:THE FOLLOWING LICENSE 'w A$ JOURNEYMAN :ELECTRI GI AN: 'Q z W LL1'AM D BER'ARP W 'z ,L 28-1 MOOSE` MEADOW'' DR R 1 EMC}NT 3354 Nl o3o41f ! ! Date, ............................. .... °F µORrol TOWN OF NORTH ANDOVER PERMIT FOR WIRING ;,88ACHU5���� i This certifies that ......... � � has permission to perform wiring in the building of Dk ........ ar ....................... orth Ando.�er, Mass. Fee.. ............... ° .. ELECTRICAL INSPECTOR Check# ' Commonwealth ®f Massachusetts Official Use Only Permit No. 1 �� Department of it wires Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank APPLICATION MIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CYR 12.00 (PLEASE PRINT INMK OR TYPE ALL INFORMATION) Date: X)31,)- O / I/ 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) Zf E o (,-ed,i soti-►�: �vc s C% ( ) Owner or Tenant 16 l-n OKS "f" I Telephone No. Owner's Address 16 ,,c"i &4 Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building c ki oe 1 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 Location and Nature of Proposed Electrical Work: �'��C t/iC�i� (, Mc �jr ►c. .�;�-. ` � �;�� Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell: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- Elo.o mergency Lighting rnd. rnd. 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 Deuces No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained p Totals: '" " ' ""'" Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P g Connection urity No.of Dryers Heating Appliances KW Sec No.o Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Si ns - Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Te1No.of Devices or E u valent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [-BOND ❑ OTHER ❑ (Specify) I certify,tinder the pains and penalties ofpeijury,that the information on this application is true and complete. FIRM NAME: 1�t./1 e,n l l cc:rt e .The-• LIC.NO.: A"Il t` 7 Licensee: Signature �r� .02z_ > LIC.NO.: Lf0 3 ,( (If applicable,enter "exempt"in the license number line) Bus.Tel.No. 11'7� Address: /U k leAA(x s P^e e t 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 FPUHITFEE.- $ Signature Telephone No. s: ❑ 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 F?] Failed M Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTI Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comment: r Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth oftiMassachusetts Department oflndustriglAccidents Office of Investigations quo 600 Washington Street Boston,MA 02111 www.mass gov1d1a Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibly Nalne(Business/Organization/Individual): S Ft/.C�,, ret ec 1A C . Address: /I^t. S.VP L-1 - City/State/Zip: (e� e xh .0 t�13 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with 3 f 4. ❑ I am a general contractor and 1 6. ❑New oonstruction employees(fall and/or part-time).` have hired the sub-contractors 2.ElI am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. molition working for me in any capacity. workers'comp.insurance. g• ❑Building addition [No workers' comp.insurance 5• ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3•❑ I am a homeowner,doing all work right of exemption per MGL I LF]Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12•[]goofrepairs insurance .re uired employees,[No workers' required.)� 13H-0ther Te�P �al'CT comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they a're 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. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: I�C ff"4 Coif 0 I� "scf c (`' "` Policy#or Self ins.Lic.#: O R LA) &.tJ /1 Expiration Date: O i s- Job Site Address: so 6_11e"'F Pea-k -elllk 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 o.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. f cdo hereby cero under the pains anrdpenalties ofperjury that the information provided above is/true and correct. - Signature Phone#: I�� -3j�-�1 `� 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#: Date �.� f OF tiORTA# 1 3�.•. ;�•��oL TOWN OF NORTH ANDOVER * * PERMIT FOR WIRING CHU,88A F' ss This certifies that }k Vv" e N �,�° �n r� d� J6 ......... ........ ....... ......... ............................ t has permission to perform ......................................................... a .: � .. ..................... wiring in the building of C 0 �.... ', ........................................ �. at e ... �........"Andover,. Fee �� � ➢ Lia Noiyi �� .......... EL i Check# � �t� t Commonwealth of Massachusetts Official Use Only Permit No. �21;1 > Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical7/S- 27 MR12.00 (PLEASE PPUMININKOR TYPE ALL MFORMATION) Date:City or T own oh. NORTH ANDOVE4 R To the.Inspector of Wires: By this application the undersigned gives notice of his or her intention to perfo the electrical work described below. Location(Street&Number) Z/1C) crocj J z Owner or Tenant 02 Cpo �S Telephone No. Owner's Address �6,.Iec.';- A 4. Is this permit in conjunction with a building permit? Yes � No (Check Appropriate Box) Purpose of Building C flkr C, Utility Authorization No. Existing Service. Amps 1.70k Volts Overhead ❑ Undgrd No.of Meters New Servic Amps 1,7,-Ie Volts Overhead❑ Undgrd No.of Meters Number of Feeders and Ampacity /-M 4�y 1,24)lavv ),bk- " /-,VJ7d-V Location and Nature of Proposed Electrical Work: SAJV,ce - , '-i;bic '0 awi 144 Completion Lf the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires /o No.of Cell.-Susp.(Paddle)Fans No.o Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires �6 Swimming Pool Above Fi In ❑ N-O.-OYE-Mergency Lig ting Rrnd. grnd. Batter v Units No.of Receptacle Outlets 7L) No.of Oil Burners FIRE ALARMS INo. of Zones of Detection and No.of Switches 3.2 No.of Gas Burners No. Initiating Devices 30 No.of Ranges -- No.of Air Cond. 3 Total No.of Alerting Devices SLI Heat Pump Tons 11(W - No. of Self-Contained rO a ..........................I.........................I................ Detection/Alertinj4 Devices No.of Waste Disposers Totals: I Number I Tons ..... Municippl ytt No.of Dishwashers Space/Area Heating KW Local 0 Connection Othe No.of Dryers Heating Appliances KW Securityof D Systems:* No. evices or Equivalent No. of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts . No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: Xaocc) — (when required by municipal policy.) Work to Start: lnspcctions 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 [BOND El OTHER El (Specify:) I certify, under the pains and ofpuiy,th at at the information on this application is true and complete.�;,/7_11 ec t FIRM NAME: 6'A (( _r,;,; fA c LTC.NO.: Licensee: "SPA-1 A. Amkcr- Signature QL -//�77,Z, LIC.NO.: ',1oS-3e:,e (If applicable,enter "exei the license number line) I'll - ,upt"in Bus.Tel.No.: *10-90y Address: le')k /e,11A?-;C .$rlee- i- Alt.Tel.No. WS- *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(checkone)0 owner 0 owner's ageni.--* Owner/Agent (1-71 m q/q _R Telephone No. ARMITFEE.- $ Signature ❑ 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 Chanter 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 Failed Re-Inspection Required($.)❑ Inspectors Co e ts: I sp ture: , c� _� L Date: !P—61—1 S E IN HAA Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: uJ(,r;�� �2 --�� - Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pas ? Failed Re-Inspection Required($.)❑ Inspectors Comments: euo Inspectors Signature: _ Date: —7_41 —/ ROUGH INSPECTION: Pass 0 Failed Re-Insp lion Required($.) ❑ Inspectors Comments: 6�G C 61e,ee --� 77 ` _ 1101.-1 1170 ` Inspectors Signature: Date: FINAL INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ..:TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com AVIL The Commonwealth of Massachusetts - - Department of IndustrialAccidents Office of Investigations IN 600 Washington Street .Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / //J Please Print Legibly Name (Business/Organization/Individual): � i ,` ,� kOec r, C. Address: /DS %4,V r City/State/Zip: 6-6-7 e t�wd g,4 0(f-S Y Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.2 I am a employer with �3 J 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.01 am a homeowner doing all work right of exemption per MGL I L[]Plumbing repairs or additions myself.[No workers' comp. c. 152, §1(4),and we have no ME]Roof repairs insurancerequired.J t employees. [No workers' 13.1-1 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information, Homeowners who submit this affidavit indicating they o're doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Ae r�z,r-d C,Ccs-c /�7 Policy#or Self-ins.Lic.#: (99 0 cL NlC S_6 Expiration Date: Job Site Address: so ������ "� /.,•t (aa t I City/State/Zip: .� �IL��✓e/` 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 o. 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 ofperjury that the information provided above is true and correct. Signature: QCL ."71, > Date: Phone#: Y 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#: • COMMONWEALTH of MASSACHUSETTS BOARD OF • ELECTRICIANS ISSUES THE FOLLOWING .LICENSE � i AS .A 'REG 'JOURNEYMA,N -ELECTRICIAN: cc JOHN .M DUNBAR !1Z ul W ( ' 49 SAL ISBURYSTREET tJ ARACUT sPVA 01826-5711 40538 j ... 07/31./16. 27178 a. STILT-1 OP ID:MH ,a�CpRn CERTIFICATE OF LIABILITY INSURANCE DA7 0310ODIYYYY) 03106/14 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 pollcy(ies)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). 1.,PRODUCER 781-914.1000 COMEACT TGA Cross Insurance,Inc. PH 401 Edgewater Place,Suite 220 aooNe Ext: ac No Wakefield,MA 01880 E-MAIL John Scanlon ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A;Hartford Ins Co ofthe Midwest 37478 INSURED Stil ian Electric,Inc. INSURER 8:Hartford Casualty Ins Co. Attn: Diane Stilian 108 Tenny St. INSURERC: Georgetown,MA 01833.1823 INSURER 0: INSURER E: INSURER F COVERAGES 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. TN TR TYPE OF INSURANCE ADDL SUB POLICY EFF POLICY EXP POLICY NUMBER MMIDDIYYYY MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE § 2,000,000 A X COMMERCIAL GENERAL LIABILITY 08SBQRX2679 03/21/14 03/21/15 DAMA ETO RE TED PREMISES Ea occurrence § 300,00 CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 2,000,000 X PER PROJECT AGG, GENERAL AGGREGATE S 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 4,000,000 POLICY X PRO- LOC Emp Ben, $ 1,000,00 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident § 1,000,000 A ANY AUTO 08SBQRX2679 03/21/14 03/21/15 BODILY INJURY(Per person) 5 ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIREDAUTOS X AU OSWNED PROPERTY DAMAGE $ Per accident S X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 4,000,000 /.� EXCESS LIAB CLAIMS-MADE T08SBQRX2679 03/21/14 03/21/15 AGGREGATE § 4,000,000 BED X RETENTION§ 10,000 `§ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY X T B ANY PROPRIETOR/PARTNER/EXECUTIVEYIN CNK6616 03/21/14 03/21/15 E.L.EACH ACCIDENT S 500,00 OFFICERIMEMBER EXCLUDED? F N/A _ (Mandatory in NH) E.L.DISEASE-EA EMPLOYE § 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I§ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION TOWNOA1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE. Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD n M ;F i j �h r i i w r i mur(i "Yi r / f ,