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HomeMy WebLinkAboutMiscellaneous - 16 High Street JIb -r�yMs��.� ` Date .:.t-,...I�................. OF NOR7h��0i TOWN OF NORTH ANDOVER p PERMIT FOR WIRING .& •g gSACMUS� This certifies that .G ` ... ..SuN I................ .. ......................................... has permission to perform .......e.......4,.'... ..�.. J......................................... wiring in the building of.........�. ..,�>,�..1„-1..!.�.�.. . at ............ .. ..... ...... .................................. . A*C* h Andover,Ma e , - Lic.No. `1 1 ELNSPECTOR .heck# :3,-t)l Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Coded�),527 CMR 12.00 (PLEASE PRINT INMK OR TYPE ALL INFORMATION) Date: V; 16 /i City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention o, erform the el ctrical w2r3described below. Location(Street&Number) Owner or Tenant L/ / �_ Telephone No. Owner's Address 171 IX Is this permit in conjunction with a bui ding permit? Yes No ❑ (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: 'Iry ZY P 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- ❑ o.o Emergency Lighting J rnd. rnd. Batter Units No.of Receptacle Outlets ` 4 No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiatin Devices g Tons No.of Ranges No.of Air Cond. Total No.of Alerting Devices No.of Waste Dis posers 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 No.of Dryers Heating Appliances KW SecuritNo.o Systems:* es or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No,of Devices or Equivalent Bathtubs No.of Motors Total HP Telecommunications Wiring: No.Hydromassage No.of Devices or Equivalent OTHER: Attach additional detail if desired,oras required by the Inspector of YYires. Estimated Value77J-714 t1 Work: / ��d (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 pal penalties of erl ,Ili at the in or icon on thi plication is true and complete. FIRM NAME: . /v LIC.NO.: Licensee: L Signature LIC.NO.: (Ifapplicable,ent `e Lnmems) � 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 coverapfofirralfy required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE:$ Signature Telephone No. i 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 em to er's defined p y x ed 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 too operate a business or to construct buildings i e P g in 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of 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 and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be .filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. c The Office of Investigations would like to thank you in advance for your cooperation and should you have any ciuestions, please do not hesitate to give us a call. F The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington.erect Boston?MA 02111 Tel,#61.7-727-4900 ext 406 or 1-877:MASS.A.FB Revised 5-26-05 Fax#617-727-7749 wwVtranass.gov/Glia GOMMONW �.TH OF MASSACHUSETTS BOAR LECTR1CiAN, I;;SSUES THE FOLLOWI N6 L;I CENSE AS :.,A REG - T"ERE'D MASTER E;LECTR I C I AR.... � a'0l1NG & SON ELECTRIC CO N MI ROSLAV 5 MLAI}Y 2 BLOSSOM` ST tiw r�a� iRN MA 01801-5106 38+7 `A 07/31.11b 390 3 I 1 i { i Date.1.2.0..Jq............... OF NORT/y,� TOWN OF NORTH ANDOVER n PERMIT FOR WIRING ,► . ,► t SS�CHUS� a q This certifies that ..1., 4-;,.6 rui.C..S.`. ..!A2 o, . 0... Y.e .}—s U has permission to perform .. .P....C., ..!..! .. 4 .rh........................ I �f ti wiring in the building of....4-� ..�:..�.......�.P., ,,...... ......... !. r ..-�....................... at .......�. --1 ���s :. ..�...... 'r ..-�...I ...............North Andover,Mass. Fee...... ..!�). ....Lic. No. .....'.................................................................. ELECTRICAL INSPECTOR "� Check# — D Official Use Only � Commonwealth of Massachusetts pp� Permit No. �P Department of Fire Services Occupancy and Fee Checked 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 rNMK OR TYPE ALL INFORAMTION) Date: q-/If 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) /,� Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction wit a building pe mit. Yes No ❑ (Check Appropriate Box) Purpose of Building 6%., 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- ❑ o.o mergency Lighting rnd, rnd. BatterV 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 TotInitiatin Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers Totals: "'' "'"""'"' """''" Detection/Alerting Devices Space/Area Heating KW Local❑ Municipal [j Other No.of Dishwashers S p g Connection No.of Dryers Heating Appliances KW SecuriNo o De ices or E uivalent 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 Equivalent OTHER: Adach 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: ?-',--)Y-/1� 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 A undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE tV BOND ❑ OTHER El (Specify:) i I certify,tender the pains and penalties of er. thattl e informat'o o tl s application is true and complete. FIRM NAME: . Olti'�2 ��tc A7, MC.NO.:�L Licensee: Signature LTC.NO.: (If applicable,enter " empt"in the license number line Bus.Tel.No.: q��' �(4•� Address: P(� R__Cm Na MW Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work r quires Departm nt of Public Safety"S"License: Lic.No. S OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. I ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c. 143,§3L,the Q 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 tr 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 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Q Pass n Failed Re-Inspection Required($.)❑ Inspectors Comments: ' Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ti FINAL I KSPECTION: Pass ? ( Failed Re-Inspection Required($.) ❑ Inspectors Comments 0 / Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth ofll2assachusetts Department of lndustrialAcculents Office of-Investigations 600 Washington.Street Boston,.l[?A 02111 vww.mass govklia Workers'Compensation.bsuranceAffidavit:BufderslCont°actors/ElectrXeians/PIamberg A heant formation Please Print Legibly Name(Businesslorgani'zationffnndividual): Address: City/State/Zipat M'�: CC� 1 04hone M 6':)S3-1JqL) Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑I am a general contractor and 1 6. ❑New construction. employees(full and/or part time)* have hire dthe sub-contractors 2.01 am a sole proprietor or partner listed on the attached sheet. 7• ❑Remodeling ship and'kave no employees hese sub-contractors have 8. []Demolition 4 working forme in any capacity. orkers'comp,insurance, 9• E]Building addition [No workers'comp.insurance 5. dWe ate 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 11.❑Plumbing repairs or additions myself Voworkers'comp, c.152,§1(4),andwehaveno 12.QRoofrepairs insurancere icedemployees.[No workers' � .a 1311 Otliex comp.insurance required.] xAny applicant that checks box41 must also fill out the section below showing their workers'compensation policy information. T'Homeowners who submitthis affidavit indicatingthey hire doing all.work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showt agthe name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation iasurance formy employees Below is the policy afid'job site information. Insurance Company Name: Policy##or Self ins.Lic.M. Expiration Date: rob Site Address: City/State/Zip: Attach a copy o#the workers'compensationpolicy declaration page(showing tote policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL 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 ofup to$250.00 a dle or. Be advised that a copy of this statement may be forwarded to the Office of Investigations of thecoverage verification. Ido hereby cert apenalties ofperjury that the information provided alcove is true and correct, - Signature: Data: Phone#• '6_<7 'L 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#: i r • 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 moxe o£the Foregoing engaged in a j oint enterprise,and including the legal xepresentatives of aAcceased employer,ox the receiver or trustee of an individual,partnership,association.or other legal entity,p g em ploying employees. However the owner of a dwelling house having notmore than three apartments and who resides therein,or the occupant ofthe 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 shallnot 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 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 ofpublic work until acceptable evidence of compliame with the insurance requirements of this chapter have been presented to the contracting authority." Applicants PleasI,ze fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-confractor(s)name(s),address(es)andphonenumber(s)along with their certificates of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are notrequired to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that thisaffidavit maybe.submitted tothe Department o£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 requited 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 andpriated legibly. The Department has provided a space at the bottom Of affidavit for you to fin 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. )u addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current pokey information(ifnecessary)and under'110b 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-ii 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 ox permit not related to any business or commercial venture (i.e•a dog license orpermit to burn leaves eta.)said person is NOT required to complete this a£ddavit• The Office w bfInvesti Investigations would uld 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: Tho CQM-M0. wcaTthofS assachusetls - DepaximeDt offndu aX A cc c7cz�t Office ofTnveStigat iox�, 60Q Washingtm Sbxee�t Boston,,MA 02111 MASSAFE Revised 5-26-05 Fay d 617-727-7749 WWW.M?SS,g¢v1Cf1a >':q,....-`q,... ONF7Y'�R"a!,€�f'�-O IVtl,�l�3.7LC!``-rE'{L�e�il�„ ;:a�.s't � ,_ Ks ISSt1ES THE5,EOLLQW.lN L10Et�ISE AS R._ t STER€➢ SYSTE;N TECHN 1 C I AN 5_raol} a t .Rg R(l ON x}1-1+54-1.0,3 �7 tib w1•. Il'Q'.'^}-t. F mum r40iillMONW .AI.TH OF ow. 'CHI yygIM SSt1f9 TR.E.-. FOLLO tft4&`'i1 1f£:EItS-E :AaS.=. A~ t ,t €REl�' S�lS�E1� CeaTRAC'f�3F�>", ,AELI`- l cs ALARMs..•rr�rc 35 NORT} CFDIlS R f; 01450-104,3' 1159 . '0 3:;::/; 6; 4Sjig �:,-...;,. .•a. .<.,,.w.:vwy?.u.«w..:unr w>e«....w.,n ..,.<.w„..,.,.,..,,,..,.,,.,..,..,.a-.s,•..,....,..,.�.,< is t+ Y1�q�1��C �..iCeflsa: SSCO-000025 ROGERJMELLQ.J$ :, ` 35 triORTHWOOD IZI}`'' 4" GROTON MA=0145©:::. "•Y i"�'i"".'Y' 01/1912015,