HomeMy WebLinkAboutMiscellaneous - 489 Sharpners Pond Road (2) 489 SHARPNERS P
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,f NOR7h
TOWN OF NORTH ANDOVER
n PERMIT FOR WIRING
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This certifies that ..G.. ...C1n!.... ..} ..Q ..JL.0
has permission to perform ....... .....`.. ....
wiring in the building of..........:.............
..................... ..........................................
at .... � ............... ..... s .............dl'...,North Andover,Mass.
-Fee.... ..........Lic.No.j...... .. �. ..............
EL RICAL INSPECTOR
Check IF
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Commonwealth of Massachusetts Official Use only
-
Department of Fire Services Permit No. ��EQZ�tiI
p= Occupancy and Fee Checked
a Jy. BOARD OF FIRE PREVENTION REGULATIONS [Rev.im] (leaveblank
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 INMK OR TYPE ALL)NFORMATION) Date: $ 7 l/y
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) 7 I� SAA/L,o/!C/L, �iv►d f2a
Owner or Tenant Ch,,S 64aI&A Telephone No. 9 7Pr- 7
Owner's Address cA„rwt_
Is this permit in conjunction with a building permit? Yes ❑ No;R (Check Appropriate Box)
Purpose of Building I&S j 4hC—t- Utility Authorization No. Q
Existing Service Zcau Amps t iv / W,0 Volts Overhead,RC Undgrd❑ No.of Meters 1
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
V 3
Completion of thefollowing table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No.of Total
Transformers KVA r
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
Above o
No.of Luminaires Swimming Pool ❑ In- o. mergencyLighting
rnd. rnd. ❑ Batteryits
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
Tot
No.of Ranges No.of Air Cond. Tons #;Z �" e No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KWNo.of Self-Contained
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: `Jn
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 of Electrical Work: (When required by municipal policy.)
Work to Start: &/2.0 //y 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 pe ssumg office
CHECK ONE: INSURANCE K BOND ❑ OTHER El (Specify:) ,t /�t-C� /,(_0
I certify, under tliepains and rallies ofper)ury,that the information on this application is true find complete.
FIRM NAME: . If-4 L LIC.NO.: 12-111
Licensee: /levi Signature 14--�,�J_A�e� LIC.NO.: /T/ 7
If /
( applicable,enter "exempt"in the license number line.) Bus.Tel.No.•_ f 49 2-3 38
Address: Po c n Sa? j2rLAc...'f jWA_ D(o 2t, 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 PERMIT FEE: $ i
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 X
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed f
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 f
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 IN Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass M Failed Re-Inspection Required($.) ❑
Inspectors Comments: .
Inspectors Signature: Date:
p g
PARTIAL ROUGH INSPECTION:
Pass 0 Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
�t
ROUGH INSPECTION:
Pass IN Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
FINAL INSPECTION:
Pass ,ff`r Failed 0 Re-Inspection.Required.($`:).❑
Inspectors Comments:
e
_-
Inspectors Signature: Dat
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department of IndustrialAccidiias
Office of Investigations
600 Washington Street
Boston,MA 02111
UT www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lm bly
Name(Business/Organization/Individual): /2 L, ( nc.
Address: R O fox. 537
City/State/Zip: Z),-z,,4 c., l 8 2G Phone#: �'T r3' L 3
��_� U
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 I
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. Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp,insurance. 9. E]Building addition
[No workers'comp.insurance 5. FJ We are a corporation and its
required.] officers have exercised their l0 Electrical repairs or additions
3111 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 12.❑Roofrepairs
insurance required.]t employees.[No workers' 13.[i Other
comp.insurance required.]
'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 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:. #L^,0_Q-t S, Inc
Policy#or Self-ins.Lie.#: L) 2-So 1 P Expiration Date:
Job Site Address: y89 ShlaLr-4a s #0,d, AJ .City/State/Zip: MA
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: � �—� Date: 8/ nvo h Y
Phone#: 78-- S°'3 ' 2 32R
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.PIumbing Inspector
6.Other - - -
Contact Person: Phone#:
Information and Instructions '
1
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs'persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an:employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced-acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-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 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 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 permitilicense 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The CommoaweaZt of assachusetts
Department of Industrial,Accidents
Office of Investfgations
600 WashiVon Street
Boston.,MA,02111
TO,#617-727-4900 eyt 406 or 1-877 MASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mtass.gov/dia
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Date h�.................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
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This certifies that
has permission to perform Xr 0,0,z, —S,
ys
.... .............. ........ ..............................
wiringin the building.f........... ..........................................................................................
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at �T2....
Andover,Mass.
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..............................Lic.No. ................. ............
ELECTRICAL INSPECTOR
Check
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Corflimo ween offidlassachrase{fs off1dalUS Galt'
Department ofFlm Servlces Permit NO,
_ BOARD OF FIRE PREVENTION REGULATIONS
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` APPLICATION FOP, PERMIT TO PERFORM ELECTRICAL WORK Ii
All work to be erformedin accordancavrita the Massachusetts ETectr cal Code ,527 CMR 12.00 I'
(PL M- SEP.N1N.C.£N.ZNKOR TYPL•ALLMFORWYY020 Date:
City or To rS m of N,,,,,�L ro the r=ector of Wires:
` By this application the undersigned gives notice ofhis or her infentim to erJ0 the electrical work described below."
Lorafion(St-reet&Numbe) t -? r h w C"A 0
Owner or'Tenant r�`s r rrn� Telepfiona 1\To. ^77/_�/6
I' 'I
Owner's Address ! i
Ts this permit iu conjunction with a building permit? Yes ❑ No (CbeckAppropriateRox)
Purpose of Building Utility Authorization Na.
xnstng Service Amps / VoIts Overhead❑ U'rrdgrd•❑. _.No.of meters !:
New•Seryica Amps• ! Volts Overhead❑. tundgrd F1 No.of Meters I`
um er o e ars and Ampacity _ '
Loeatfon and Nature of Proposed EIectrical Work: U-)S fit ( 4k ✓f���� ,
Co Wtenon off hafollowfnP table may be waived by the Inspector of Fire s. s
L, p
No.of Total• i
um9naireOutlefs No.of Hot Tubs Genekators XVA
umi zairesAhove ❑ In- ❑ _ o.o mergencg zg ung
e�� ale
N0.of switches II\o,of Gas$urners Total No.ofDetection and f i S
.z Iiritiatin Devices €
No,of Ranges No-of Air Cond. Tons No.of Alerting Devices
No.of Waste Disposer
13eatPnmp Number Pons KW �No.ofSeIf-Contained
Totals: Deteciion/Ale Devices
Nlo.of Dishwashers S aceJArea Heatinff Muuicippai
p s � Local❑Connaetion ❑ Othe r
No.of Dryers Heating Appliances KWSecurity Systems:
�
No.ofDevices or Equivalent i
No,of WaterNo.of No,o;. Data Wiring:
Heaters x1WI Si s Ballasts No.of Devices or Equivalent qt
i
No-HydromassageBathtizbs IND.of Motors TOW HE Telecommunications Wiring:No.of Devices orE uivalent
OTHER: f
,mach additional d-tail/f desired,or as requfred by the Inspector of Fres i
Estimated Value of Electrical Work_ /L
9 (C�l71en required by municipal policy.)
Workta Start: I/t�^/ y Inspections to berequeswdiaaccordance witTiMEC Rule 10,and upon completon-
INSURANCE COVERAGE: Unless waived by the owner,no perzoit for the performance of electrical work may issue tmless
the lioerisee provides proof of liability insurance inelulding"completed operation"coverage or ib substantial equivalent, The ll
undersigned certiries that such.coverage is in force,and has exlu'bited proof of spme to the permit issuug offico,
01 CHECKONI:- INSURANCE [I BOND F1 OTHER i (Specb, .) Selflnsured
- I cet/ify,under fhepaba arzd penalties afperk'ry,thal the;rnf on this app&adan is free and complete T
+ X NAM. ADT LLC DBA ADT Swaritiy f LIC-INTO.: C 172
Licensee: 'Thomas T.Lee ignafure .LIC.UO.: C-172
(If applicable.n r�AjT�'ZMvt•"in the R e numberr,1 �L Bus.TeL No.: x
Address; / C �l/? fi ` lfc�i �1� 'fJuO / Ait:Tet No.:�:L�u..c�'L��6 11
TSecurtr System CoatractorLicense pgokod fox this work;if applicable,enter the license number here: 001779
OVME+R'S IN : I atn av,wG that the Licensee does not have flea liability insurance coveragenot-anally
requ�ed by 1a . B m si be w,Thereby waive this requiremCat I am.the(check one)❑owner �ar's agent
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a oorp pa-tion and air 1 �����i�oca�deg tti��xr a�lri�tiu�r�s
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