HomeMy WebLinkAboutMiscellaneous - 16 High Street Suite 201 � ') _ _ n
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S M E A 6
KEEPING YOU ORGANIZED
No. 10301
PATENT PENOWO
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MADE IN USA
GET ORGANIZED AT SMEAD.COM
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` Date........ ...:--�....................
1 �NOR7F�,
° tia TOWN OF NORTH ANDOVER
* * PERMIT FOR WIRING
416-
l
CHU55t
This certifies that .............w ( .<.. .......i�.. � e .r�r
....... ........... ...... . ...........
has permission to perform .....(... . ... w ,fl...... c,,./........
wiring i the building of................PC
.....................................................................................
at .......... .!........ .....1. .7...........45;.7.. ..................n.......,North Andover,Mass.
Fee..... --'�""....Lic. No. I .Z.. ;..............h,
/[�l. .�� .1! .�!....
! ELECTRICAL INSPECTO$k
E Check#
1 ? ? 7 ;
Print Form
(,ammoruaealth o�rr/aa sachuSel Official Use Only--
Permit
nly Permit No.
t3-2 76
i
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS ptev.1/07] leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code //C),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:��—
City or Town of: \1 p1 -r ,Q&;DcyLN2 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)
Owner or Tenant yP Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ NoF±1 (Check Appropriate Box)
Purpose of Building 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:
;l
Com letion o the ollowin 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- ❑ o.o Emergency ig ng
f rnd. rnd. Batte Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
i No.of Switches No.of Gas Burners No.of Detection and
IWtiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons g
No.of Waste Disposers Heat Pump I Number Tons KW No.of Self-Contained
Totals: _ .....-----------.._. .._......_.__.. Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal 0 Other,
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
'
Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or E uivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value ofElectric aI Work: (When required by municipal policy.)
Work to Start: r / Inspections to be requested in accordance with MEC Rule 10,and upon completion.
t INSURANCE CO ERAGE: 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
t 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 and penaides of perjury,that the information on t s plic 'o true and complete.
FIRM NAME: DAVID ELECTRICAL CONTRACTING LLC LIC.NO.:
Licensee: DAVID HAGGAR Signature LIC.NO.: 14963
(Ifapplicable,enter "exempt"in the license number line) Bus.Tel.No.-978-682-6262
Address: 87 BELMONT ST, NORTH ANDOVER, MA 01845 Alt.Tel.No.:978-375-5734
*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 a ent.
Owner/Agent
Signature Telephone No. PERMIT FEE. $
Date......tl—J.—/z.*�
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
4L
ass^
CHU
Thiscertifies that ........................................................... .............................
has permission to perform ......... z F. .........
wiring in the building of..... ......4a ?x.PkWVC
at..........1- ..'i-�-K"I.A/.......... ............2.North Andover,Mass.
pFee..:�� Lic.No. ....... . .......................... ............ ..
ELEmICAL INSPECTO
Check #
10462
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.Irlsptctor_of_Wires abandoned-and-invalid-if-he—
_
or she has determined that the aVherized work has not commenced or has not progressed dm'in_g the preceding 12-month period.Upon written
application,an extension 14 time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner ur.the installing entity stated on the permit application.
F1 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 15,2 8 and extending'through August 15,2012.
:E *--"
Permit/Date Closed: * mote:Reap- ply for new permit
❑Permitxtension Act—Permit/Date Closed:
Comrnonwaa& of MaseacLaffa Official/Ilse Only
lug
cc� Permit No. /b �
.1Japarl nwiE oire Sarvica9
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work t6 be performed in accordance with the blassachusens Electrical Code(EIEC),j27 C.IR 13.00
(PLE ISE PRINT IV LVK OR TYPE ALL 1VF0R4,L4TION) Date:
City or Town of: Ar1j&-fe- To the Inspector of Vires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below. i
Location(Street& Number) S,F
Owner or Tenant rr 1 ei ( S Telephone No."-
Owner'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 Overhead ❑ Undgrd❑ No. of Meters
New Service Amps / Vohs Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical.Work:
Eomt#erion of the following table may be waived bi•the 1rsvector of[tires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total
Transformers
ansformers KVA
No.of Luminaire Outlet IN'o.of Hot Tubs Generators KVA
No. of Luminaires pool Above In- o.o mergence is ting �C
Swimming yrnd. grnd. IBattery Unit
No. of Receptacle Outlets No.of Oil Bunters FIRE ALAPAIS INo. of Zones
No. of Switches INo. of Gas Burners No. of Detection and
Initiating Devices
No. of Ranges No. of Air Cond. Total
c Tons No.of Alerting Devices
No. of Waste Disposers Hear Pump Number .Tons 1 K.N ' No. of elf- ontained
Totals: l Detection/Alerting Devices
No. of Dishwashers Space/Area Heating KW Local❑ Municipal
Connection ❑ Other
No. of Dryers Heating Appliances KW ecurity Svstems:, �— ::]
No.of l5evices or E uivalent
No. of NaterKWNo. of No. of Data Wiring: �, t
Heaters Sions Ballasts
No.of Devices or Equivalent
P No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER: M/Q r M
p - Attach additional detail If desired, or as required by the hispecior of I tires.
Estimated Value of Elect ical Work: -` (When required by municipal policy.)
Work to Start: l ti t{ 1) Inspections to be requested in accordance with NEC 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:) Self Insured
I certif,,under the pains and penalties of perjury,that the ' ormation on this application is true and complete.
FIRM NAME: ADT Security Services LIC. NO.:
Licensee: Mark A. Brophy Signatu e LIC. N'0.: C-45
Ilfopplicdble, enter "ezentpt"in the license number line.j Bus.Tel. No.: 6 0 3 -5 9 4-5 9 2 8
Address: 18 Clinton Drive Hollis NH us.Tel. No.:_
*Per M.G.L. c. 147, s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. 00953
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally F
required by law. By my signature below, I hereby waive this requirement. I am the(check one)❑ owner ❑owner's agent. I
I Owner/Agent 77
Signature Telephone No. LF4RMT FEE. $ S
a
CEPART::ENT OF PUBUC SAFETY
�'1:i`-•`„ ,.,�a�t ftM t a, - CA --'�i1. Y,'� S•U—flse
A_R EGISTERED SYSTEM :, ..`G:�;•ii Nutnbcr, SS CO G0-7:53 .
::sh"=`:•'-�ISSUESTIH ABOVEUC:NScTO: "•;= Expiras: QT07•'"�: Tr,no: I17.0
O -,SE 'SERV LCES'f
cD T, . 'CU R I TY. E s-Li«nsa: ao T S,cuRlrY Set rlcE
- - ..MARK-.A .BROPHY..SR :E
41p ..uNIVERST_TY- AVE -
;,IARK 1. 9ROPHY SR
. - .. 0Z094 .1. _`,.
41E S TW QO D r. :�4R:v000, tdA"0?�5Z
. ..-•� 45 C p7/31/13 ..`. 849174 : [ . -- - -- -- --- -- - - -
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Date...115.1.14........
10723
Of".ORr"�ti TOWN OF NORTH ANDOVER
° p PERMIT FOR PLUMBING
t �s+cHuss
This certifies that....&..........H.9-00!1 N.......................
..... ...... ........
.......... ..... .....
has permission to perform.......r-�1.. `?..s.....c-�.! ......................
plumbing in the buildings of...t.C. ,.4.. 5.},.,.N A:.....................
at....1..1s--1..�. . ...c' :.... �:........, North Andover, Mass.
Fee9. .......Lic. No. ..... ... .!Pr...........................................................
PLUMBING INSPECTOR
Check# L
�MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMIB/I`N�G1 WORK
CITY \1 6Qty ANbdxjP;k- MA DATE I y PERMIT#low
tU 1
JOBSITE ADDRESS 1 (Q (4I top f)/>--OWNER'S NA�1E
,,.7v1.�7�bs f/cz
OWNER ADDRESS A�� S! TEL 6o/7 l: 2 � FAX
� �v
TYPE OR OCCUPANCY TYPE COMMERCIAL(� 1 EDUCATIONAL ❑ ESID;NTIAL❑
PRINT
CLEARLY NEW:�K RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR 1 AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK
LAVATORY
ROOF DRAIN
.. SHOWER STALL
SERVICE I MOP SINK -17
TOILET
URINAL
WASHING MACHINE CONNECTION _
WATER HEATER ALL TYPES
WATER PIPING
OTHER tt
1P
INSURANCE COVERAGE: /
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES IJ' NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my kn6-W— ge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of th
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME &6 114e- (.,13rm et( LICENSE# 453b; SIGNATURE 1
MP Y JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAMEc'��`��T�d'LS /,�ir�/��G� ADDRESS l0 /C��fJ�`—i S✓i z
CITY 1-►�0�U2 1� STATE
rr ZIP TEL a 1'7�7
V
FAX CELL Z� �p �/ C1 EMAIL ��i i G�/�l'c.�yi•�1.7� �,,JPC.
1�® ,cum
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J
whe Commonvearth ofHaxyachasetts ,
-
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parfivint ofInc�xs; it�Acczc e is
• .
Office offfives igafeons
00 WashifleonSfreet
-Halton,HA 02111
vw mass gov/cixa
•prcke)cq'CompengaflonbsoxanceAffidavit: erg
App c�x�.f orcanafzo Please.rrkt:Lew
Hama(Businessl0rgaaizationlln&1dizaZ}: �1G-C�.0 CJ�7 et� /�
Ci-�yt�tat�t��:, ���fJ2�2.� Pham�:, ��'l�/� • � ( 7-7.
.
.ire po employer?Cbeck,the�a xopxiatohox: 'Type of project(required):
` 4, 11 Z am a genexal contxactox and x f
x,�exaaplopex with 6. �New construction
employees( anc oxpax time):
have noMesub-contxactoxa
- listed on the attached sheef� 7. [1 Remodelling2.[] 1 am a sole proprietor or paxiv ex
Ship and`haveno•employees These sub-contxactoxshave 8. []�}demolition
working for me in any'capacity. woxkers'comp.insurance• 9• ding addition M
[To woxkexs'comp.ftmance 5. ❑We are;a corporation andits 10 El EleetriealTop alts or additions
xegaked.] officers have exercised.their
3.El X am a homeowner doing allwoxk xzght of exemption.lrexZt/OL 1I..��'lumbingxepaixs or additions
mpsel-F[No Wgrkars,'comp. c.152,§1(4),andwehaveno 12.PRaof16P aks
in aarancezecluixed.� employees..[Naworkexs° 13.0 OtTiex
comp.insurance required.]
4Aty applicant that cheeks box Al must also iill ouithe section,below A0V1ngtheir worke're compensation.policy luformafiom
i HOMOowners who submitthis affidayitkdloatnjtW Re doing allworgand then hire outside contractors must submit anew afddavitindicatIug such.
xCon-tractors'diatcheckflusbc�mnstatfachedan.addifienalsheetshow.ingthezrameofthesuh-eonfraeforsandtheirworkers'eomp.policyinformation,
I tcm are exnpro �t'thcc i p ovidi�tg tuQ� e 'cornpe satfon znsurarteefo•�,�y ern�royees: Serow a fie to iey rr�t jo ,�iz`e
ire,fox'.mtttio�2. .
Insurance CompanyNama'.
/
L, �sG� ,ear Exl�ixrnDate• j zd/S
Policy#or deli ins..l�.c.#_ � ..
lob Bite.A Address--/�a
-Attach,a copy agt�ewoxker$,compensatioxt-polx`ey declaration page(show-i g•tRe,policy number and expiration date).
Failure to securo covoxage as xecluixeclunder Section25.A.ofMOL o.x52 can lead to tlxe impositien ofexirninaxpenalties of a
z• 0 ORDMand afmo
$ne,up to$1,50 0.0 0 andlox one-pear z�nprisoumexzt,as well as civalpenal�zes in the form ofa STOJ?W
ofup to$250.00 a day againstthe violator. Be advised that a copy ofthis statomentmaybe forwardedto the Office-,of
ante coverage•verification. .
Xnvestigatzons ofthe DU for msnx ag
xdoiiereby ee �icferge�iain,�c�ndver aldego�pe�jurytXicritrieir2 o rtr ior�p�oVz ec;�c�boYe?s zteant�corree
Si afore: Data:
Thone
3/4
offlciaZ use oAfy, .Do nojw.?zte in triis area,to tie eorrryTeted by city or town official
City or Town.: Ferrnztl�iceuse#
fmaingAuthoxity(circle Mao);
Z.Baaxd of�fealth 2.RuiidiugDepartment 3.CityMom Clerk 4.Electrica]lluspector 5.Numbing Inspector
6 Otbter - - -
Information and instructions .
Massachusetts General Laws chapter l52 requires ail employers to provide workerscompensation for them employees.
Pursaaa t to this statute,an erapfoyee is dofmad as`°...every person hi the service of another index any coiftet oXhire;
express orknplied,oral oxwxiffen?,
Art era loye is defined as"an individual, axtnexship,association,coxpoxatzon o:c othex7-egal entity,ox anytwo oxmore'
oftheforegoingengaged inajointenterprise,andincludingkolegalxepresentativesofa•deceasedemplQ ex,.orthe
receiver ofxusfee of an individual,parinersh%p,association ox otS�ex Zega1 entity,employing employees. 1Sovtever the
owner of a dwellinghousehavingnotntoxethaathxee apartments audwha xesides therein,orfhe ocenpantofthe
dwelling house of another who employs,persons to do maintenance,construction orrepair woxlg ort such dwellinghouse
or on the grounds or building appurtenant thereto shall not because of such employment be deemedto be m employer.,,
MQL chapter 152,§25C(6)also states that"every state or local Rmusing agency slnalz withhold the issuance or
renewal of a llcernse orpermit to operate a business or to const'
xact bnildfngs in,the comxnaxtwealth for any
applicaxtt who has not pro duced.acceptable evidence of compliance nth.the insurance coverage required:'
.Additionally,MGL chapter 152,§25C(7)states"Neitherfhe commonwealth nor any of its political sub6i'sions shall
entex into any contractfor the performance ofpublie worduntil acceptable evidence of compliance with,the insurance
xegaixemenfs of this chapterhave beenpresentedta the contracting authority.."
.Applicants
Pleas,o AR out the Workers'compensation affrdavt completely,by checlting the boxes that apply to your situation and,if
iiecedsary,supply sub-confractor(s)name(S),addresses)and�honenumb ex(s)along with their cerneafe(s)of
k9wauce. Limited UabilityCompanies(LLC)or Limited Liability l'artnerships(LLp)v�thno employees othorthatn,the,
members orpattners,are notregakedto carry workers'compensationinsttrance. If anLLC orLLp deeshave
employees,apolicy is required. Be advisedfhattbis afdavitrnaybe sabmitiedtotheDepatfinent of Industrial
.A.ccidents fox confirmation of insurance coverage. Also be sure to sign and date the aitzdavi. 11e affidavit should
bexetomedtothe cityortownthattheapplicatignfox fhepemftorlicenseisbeingxegaesfed,rto theDepaxtmentox
Industrial Accidenfs. Shouldyou have any questions regardingthe law or if you axe requu ed to obtain,a*orlcexs'
compons ationpolioy,pleas0call the DeparbnentattltenumbexIto dbeZow: Selfinsuredcompaniesshouldenfertheir
self-huxanco license number on tha appropriate litre.
City or Tom OfUcials
Please be sure that the affidavit 1s complete andpxinted legibly. The Departmentlnas provided a space atthe bottom
ox the afddavitfoT you to sill out in the event the Office of Investigations has to contactyou regarding the applicant:
I?lease be sure to filllnthepexmxf/Izcensenumbexwhicb vritl be us\d as a reference number, In addition,an applicant
thatnnzust submitmultiple pemzif/Iicense applications inn any givenyear,need only submit one azizdavit indicating current
PORGY infoxmadon(ifnecessary)and under"3'ob Site Address"the applicant shouldwxite``alllocations in (city or
tOWZ) :A:copy oAho affidavit thathas been ofdciallysfamped orm.arked by the city ortownmaybepxovided to the
applieantaspzoofthatavalidafFidavit•sson le ox�5xfvxepemsifso,licenses, .AnewazffdavitmusthaMedouteach
year.where ahome owner or citizen is obtaining alicense cxbennitnotrelafedto anybusiness or commercial venture
(te,a dogReeznse orpermitto burn leaves ete.)saidpersonis N'OTxegairedto complete this affidavit.
The Office of Xnvestigations would Eke to thank you in advance for your cooperafion and should you Have any questions,
,please do nothasitate to give us a call.
The.Depariment's address,telephone aztd fa�numbex:
T110 GQQx� �at of {sa�?vaP
600as gtw
f�
I
COMMONWEALTH OF mASSACHUSET
•
PBOARD C�1~
GASFITTERS
y i:UMt3 14
I I.S'SIJES THE f OLLOW
L.I GI=N`S D AS A {gSTER PL.UMD
R06E-AT A
MCC LL JR
'24 GU
:;;:> 21 -44, 3";
a1E0FORD MA o 55
�I2-7I14
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f
a I—V
-,A ru 9 ,
BUIDWc-WOW PRO VJOUIV-�--
i � V
.............
TOWN OF NORTH ANDOVER
VR
PERMIT FOR WIRING
lqu
This certifies that
. ........
.................................. e.,9..........
has permission to perform ........ .......(1)04............................
wiring in the building of......... (' 4C
.....................................................................................................
at ....... .....2...` IT /0"<-...,PrthlAnaover,Mass.
17 .........
Fee.j......!�� ........
.. .Lic.No. ................................. .............. ... ....
ELEc-mcAL INSPE OR
h-15"0
Check S
12373 776-IV 0" X11, IV
Commonwealth of Massachusetts Official Use Only�f
s Permit No.
Department of Fire Services
Occupancy and Fee Checked
,M BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07] leaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date:
City or Town of: NORTH ANDOVER To theIn pector of Wires:
By this application the undersigned gives notice of his or her intention to perform the ele trical work described below.
Location(Street&Number) -Zt,, OAT—ione
Owner or Tenant No.
Owner's Address l2 /UAl-20
Is this permit in conjunction with a building permit? Yes,K No ❑ (Check Appropriate Box)
Purpose of Building �Oid�t�l�'L�/�� 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:
Completion of the following table may be 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- ❑ ITOT o mergency Lightmg
rnd. grnd. Battery Units
No.of Receptacle Outlets �f No.of Oil Burners FIRE ALARMS No. of Zones
No.of SwitchesNo.of Gas Burners No.of Detection and
3 Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons
No.of Waste Disposers Heat Pump Number Tons KW _ No.of Self-Contained
p Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
! Heaters Signs Ballasts No.of Devices or E uivalent �1
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or E uivalent
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,under the pains and enalties of perjury,that the i n2ation on ' application is true and complete.
FIRM NAME: . / ' LIC.NO.:
Licensee: Signature LIC.NO.:
(If applicable,enter{' "exe pt' i t li Um er line.) Bus.Tel.No.:
Address: �i Alt.Tel.No.: x`77 j'
*Per M.G.L c. 147,s.'57-61,security work requires Depa en ublic 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: $ U—
Signature Telephone No.
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the /' A
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed
electrical permit shall be issued to the person
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
, 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 conceming 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 Ins ection
Pass 0
Ins Failed
Re-Inspection Required($.)❑
Inspectors
Commen
rs
p
ts.
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass Failed
Re-Inspection Required($.)❑
Inspectors Comments: .
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass Failed
Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INS ECTION:
Pass 0 Failed
Re-Inspection Required($.) ❑
Inspectors Comment .
Oo
I
Inspectors Signature:
Date:
7fts
' AL INSPECTIO
s[N Failed 0
Re-Inspection Required($.) ❑
nspectors Comments,
I
2 3�/
Inspectors Signature: i
Date:
:B WEINHOLD
...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
The Commonwealth ofMassachusetts -
Department o•flndustrialAcciderzts
Off-zce offfivestigations
600 Washington Street
Boston,MA 0 111
www.massgov1d1a
Workers'Compensation insurance Affidavit:Bui lders/Contractors)Electriclans/Pliimbers
Applicant Information Please Print Legibly
Name(Business/Organi'zation/tndividual): 7 v�P/� ` �2 Ag
Address:
City/State/Zi p: �� Phone : z.�W_
Are an employer?Check the appropriate box: 'Type of project(required):
I:( I am a employer er with 4• ❑x am.a general contractor and I 6•
J p y EJ Now construction
employees(full and/or part-time).* have Hired the sub-contractors
2A❑ I am a sola proprietor or partner- listed on the attached sheet. 7• F1 Remodeling
ship and'have,no employees These sub-contractors have 8. [(Demolition
working for me in any capacity. workers' comp.insurance, g• E]Building addition
[No workere comp.insurance 5. ❑We are a corporation and its I0.[]Electrical repairs or additions
required.] officers have exercised.their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c.152,§1(4),andwehaveno 12.❑Roofrepairs
insurancerequired.]i employees.[No workers' 1311 Other
comp,insurance required.]
X.Any applicantthat checks box#1 must also filloutthe section below showing their Workers'compensation policy information.
l-Homeowners who submitihis affidavit indicatingthey are doing all work and then hire outside contractors must submit a new affidavit indicating such.
TContractors that check this box-must attached as additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
f am an employer that is providing workers'compensation insurancefor my employees Below is the policy and job site
information.
Insurance Company Name:.
kdolicy 4 or Self-ins.Lic.ff: Expiration Date:
Job Site Address: v City/State/Zip:
Attach a copy of the workers'compensation-policy declaration page(slowing the policy number and expiration date).
Failure to secure coverage.as requixedunder Section 25A ofMGL 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 AIA for insurance coverage-verification.
mo Iiereby cert&uncle ains and �alflesrkry thatthe information provided above is true anti correct, -
Si afore• Date:
Phoneff:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit[License 0
Issuing Authority(circle(5ne):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other -
Contact Person: Phone M
r�
Information and Instrnctions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an erl�ployee is defined as".,.every person tri 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 employes."
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 fox•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 ofpublic 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'compensailon affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)andphonenumber(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 notrequired to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. the affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain.a-workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete andprinted Iegibly. 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
thatmust submitmultiple permit/license applications in any given year,need only submit one affidavit indicating current i
Policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations is .(city or
town):'A copy of the affidavit that:has b een officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit-ii on file for future permits or licenses. Anew 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 orpermit 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 aitd fax number:
eo OXkw0a1th0fV_ ssadhV.&ottq -
Deparbo at ofkadu aI A cc da t
Of Roe of JAVe.SUgAUo.�,%
60 W44-hpgt(a Sjxeot
Boston,MA 02111
TO.#617-727,4.900 QA 406 ox 1.-•877- .
Revised 5-26-05 Fay,#617-727-7749
COMMONWEALTH OF MAS'SAOHUSETTS
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