HomeMy WebLinkAboutMiscellaneous - 4 High Street Maker Mill-Suite 128a
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Date........ ...............
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
..... .. .......................... .....................
has permission to perform .............. ..... �-.Y`.� . . ..... 7 ... C.Yf�)r� No, 5
wiring in the building of ...... . ..... U -X-4 . . ....... ..............................
d
. ............................................. .................... . N
at ....... _�h An over, Mass.
Lic. No.
Fee .............................. ... . . ................. ... ... . ........ ... . .. ......
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ELECTRICAL INSPECTO
01LA- I-
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Commonwealth of Massachusetts Official Use Only
Permit No. 1 , 61
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 0 ,
w„ (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date:
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives otice of his or her int tion to perform the electrical work described below.
Location (Street & Number) u ^-
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a bu' ding permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building CI�y�/��-r&� 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:y,
Completion ofthe following table may be waived by the Inspector of Wires.
I
No.,of Recessed Luminaires
,
o. of Ceil.-Susp. (Paddle) Fans-
No. of Total
Transformers KVA
No. of Luminaire Outlets `"
No of Hot Tubs
Generators ` . KVA
s
No. of Luminaire
Swimming Pool Above ❑ In- r,
rnd. rnd.
No. o Emergency Lighting . r�
Battery Units ` KJ
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 Devices r
No. of Ranges
Tot
No. of Air Cond. Tons
No. of Alerting Devices �N
No. of Waste Disposers
p
Heat Pump
Totals:
Number
"" " "
Tons
' '' "
j.KW
............
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
p g
LocalEl ❑ Other
Connection
No. of Dryers
Heating Appliances jar
SecN oto.o Systems:*
s 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: f
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electr' al Work: fr4V (When required by municipal policy.)
Work to Start: //4 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 thepains and enalties�yof.Psrrye info non on t application is true and complete.
FIRM NAME: , O !� r LIC. NO.:
Licensee: `/ W/ Signature LIC. NO.:P,
(If applicabl , enter "exempt" in the license umber line.) Bus. Tel. No.:
Address: J'®e i��D 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 signalure heel w, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent PERMIT FEE. $ J2(
Signature °7 A%� (¢ Z Telephone No.
t�T
❑ 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 s
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 R
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass _
Failed (]
,,Re- Inspection, Required ($) 0, _
Inspectors Comments: "
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass M
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH PECTION:
Pass
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Co a s:
Inspectors Signature:
Date:
FINAL INSPECTIO :
Pass 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comm ts:
Inspectors Signature:
Date:
0W
DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com
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The Commonwealth ofMassachusetts
Department of IndustriglAccidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Address:
City/State/Zip:
#: b;,' fro° �'�0-71
Aro,you an employer? Check th e appropriate box:
1.am a employer with ( 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I
ship and'have no employees These sub -contractors have
working for me in any capacity. workers' comp. insurance.
5. ❑ We are
co oration and its
[No workers' comp. insurance 1 rp
—,,r,r 4
�._. officers have exercised their
required:] ✓ �.
3. ❑ I am --homeowner doing all work right of exemption per MGL
myself. [No workers' comp. c. 152, §1(4), and we have no
insurance required.) i employees. [No workers'
comp. insurance required.)
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11:❑ Plumbing repairs or additions
12.❑ Roofrepairs
13.❑ Other
!Any applicant that checks box#1 must also fill 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 anew 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. ti
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:,
Policy # or S elf -ins. Lic.
��
Expiration Date:.
Job Site Address: �% r(( t/ �! U i Cifylstate/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 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
f do Hereby cert fy under the ' s andpenaldes ofperjury that the information provided above is true and correct.
Signature: Date:
Phone 9:
���
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. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
- - -
Contact Person: Phone
1\
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 le boxes that apply to your situation and; if
necessary, supplysub-contractors) name(s), address(es) andphonenumber(s) along withtheir 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 (ifnecessary) 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. Anew affidavit must be filled out each
year. Where a homeowner or citizen is obtaining a license or*- ermit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, J
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Cowmollwoalth ofMassarhusetts
Department offadustijal .Accldants
Office of1"estigatiow
600 Wa.shingtou Street
Boston, MA 02111
TQL # 617-727-4900 ayt 406 or 1-877:MASSAFE
Revised 5-26-05 Fay, # 617-727-7749
'(tFcxFi7rmonn rrnzr�.a:; ..
MMONWEALTH OF
NORTH ANDOVER BUILDING DEPARTMENT
1600 Osgood Street
North Andover
Tel: 978-688-9545
Fax: 978-688-9542
.BUSEVESS F0J?M.FOR TOWN CLERK
DATE: , b
NAME- Th P V 1 lr 1� P
LLC-
ADDPXSS*.-
All 6S .I�
,ONING DISTRICT: S
TYPE- OF
BUILDING LAYOUT PROVIDED: YES NO
A- AILABLEPARKMCr' SPACES:
ZONI NG BY LAW USAGE: YES NO
13USINESS FORM FOR TOWN CLERK
2.40 Home Occupation (1989132)
An accessory use conducted within a dwelling by a resident who resides in the dwelling as his principal
address, which is clearly secondarsr'to the use. -of the building. for luring purposes. Home occupations shall
`include, -but not 'limited to the following uses; personal services such as finished by an artist or instructor,
but not occupation involved with motor vehicle repairs, beauty parlors, animal kennels, or the conduct of
retail business, or the manufaciuxing of goods, which impacts rule residential nature of the neighborhood.
4. For use of a dwelling in any residential district or multi-f4mily district for a home occupation, the
following conditions shall apply:
a. Not more than a total of three (3) people may be employed in the home occupation, one of
whom shall be the older of the home occupation and residing in said di wMag;
b. The use is carried on strictly within the principal building,
c. There shall be no exterior alterations, accessory buildings, or display which are not customw
with residential buildings; -
d. Not more than twenty- fiiTe (25) percent of the existing gross floor area of ;the dwelling unit
so used, not to exceed one thousand (1.000) square feet, is devoted to such use. 7n
connection with
such use, there is to be kept no stock in trade, commodities or products which occupy space
beyond these limits;
e. There will be no display of goods or wares visible from the street;
f. The building or premises occupied shall not be rendered objectionable or detrimental to the
residential character of the neighborhood due to the exterior appearance, emission of odor,
gas, smoke, dust, noise, disturbance, or in any other way become objectionable or
detrimental to any residential use within the neighborhood;
g. Any such building shall include no features of designanot custommy in buildings for residential
use.
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iigriatA V(((��� Date