HomeMy WebLinkAboutMiscellaneous - 668 Osgood Street t ly
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BUILDING FILE
Date. ! t
NowrM
TOWN OF NORTH ANDOVER
9 PERMIT FOR WIRING
HUs�
This certifies that . a..--- - ... �!�.......
...................................... . .
has permission to perform ...........�j - ,f1 Jt C�.-...................................
G wiring in the building of........
at .. ... � '.....S". .. ..........
rth Andover,Mass.
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Fee........................Lic.No. . ....... i. .
...EL cru.IxSPECI'OR
Check.-
12361
heck#12361
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Commonwealth of Massachusetts Official Use Only
1
•`` Department of Fire Services Permit No. � La J
Occupancy and Fee Checked
,M 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(NEC),527 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: 5/ 1 ?1/-/
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or herintention to perform the electrical work described below.
Location(Street&Number) S (70 0Ib 5
Owner or Tenant .—i i:b, Telephone No.
Owner's Address ?�rtSvLrG,4-j P0,f
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building Utility Authorization No._1`�t S`i-j
- Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity a'
Location and Nature of Proposed Electrical Work: f�-,-,v( P L f},,_ S C-?W CO;
Completion of thefollowing table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total c-=
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- ElNo-.-OTEmergency Lighting
rnd. grnd. 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 Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons
No.of Waste Disposers Heat Pump I Number I Tons KW No.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:
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 9 res.
Estimated Value o Electrical Work: (moo Q(21` (When required by municipal policy.)
Work to StartM Q f Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERA E: 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 cover is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE Y BOND ❑ OTHER ❑ (Specify:)
I certify,arn(lei,the pains and penalties ofperjury,that the information on this application is true anti complete.
FIRM[NAME: . ILC__ LIC.NO.:/1' 2
Licensee:,�ALC. A_C L EZ)OA/A��kignature LIC.NO.: Z7 JD -
(If applicabl nter "exempt"in the license number lin Bus.Tel.No.- 3 cY Z- nt
Address: V�00 pj D 6 � 0 1 Z L_. - 1, td r4' Dtk 3 !�- Alt.Tel.No.: b 2-
*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 gent.
Owner/Agent
FP
Telephone No. ERMIT
FEE: $
Signature
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
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 F
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.
F1 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
"i11 n e11 ffe11 ct o11 r 1.existen11 ce11"d11 u11 ring the qualifying period beginning on August 15,2008 and extending-through August 15,2012.
11
11
11
❑ Rule 8—Permit/Date Closed: 'Note:Reapply for new permit❑
❑Permit Extension Act—Permit/Date Closed:
Trench Ins ection
Pass n? Failed 0
Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass M Failed
Re-Inspection Required($.) ❑
Inspectors Comments: .
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass n Failed
Inspectors Comments: Re-Inspection Required($.)❑
Inspectors Signature: Date:
ROUGH INSPECTION:
Pass M Failed
Re-Inspection Required($.)❑
Inspectors Comments:
i I
Inspectors Signature: Date:
'INAI.,INSPECTION:
Pass 0 Failed
Re-Inspection Required($.) ❑
nspectors Comments:
i
Inspectors Signature: I
ate:
:B WEINHOLD ...TOWN OF MERRIMAC,MA.
.......dweinhold@townofinerrimaacom
The Commonwealth ofMassachusetts -
DepaYtment of lndustrucl Accidle -ts
Office oflnvestigations
6001 Washington Street
Boston,MA 02111
-www.mass:gov/dia
Workers'Compensation Insurance Affidavit:Builders/Cont°actors/Electricitans/P]iunbers
Auulican> orma ion Please Print Led ly
'Name(Businesslorgmi-zation/Tndividual): ,1�l ✓v� —�— �Lt���T't Com_
Address: Qsa 7.c Mobs
City/State/ZiCXS
p: �.v �4-✓� �Lc� .M�'f- Phone#:
Are yw an,employer?Check the appropriate box: Type of VyAukeet(required):
1.9I am a employer with 4. ❑ x am a general contractor and I '
6• ew cbnstraction
employees(fall and/or p -time)* have]fired the sub-contractors
2.❑ I am a sole proprietor or partner listed on the attached sheet. 7• ❑Remodeling
ship aud'liaveno employees These sub-contractors have 8. []Demolition
woridng forme in.any capacity. workers'comp.insurance. g• ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its l0,[]Electrical repairs or additions
required.] officers have exercised.their
3.❑ I am a horn.eowner doing all work right of exemption per MGL UE]Plumbing repairs or additions
myself.[No workers'comp. c.152,§1(4),and we have no 12.[p Roofrepairs
itisurancere ed. employees.[No workers'
a 13.[]Other
comp.insurance required.]
xAny applicant that checks box#I must also fill out the section bel6w showingtheir workers'compensation policy information.
'Homeowners who sabmit this affidavit ind catingthq 2•re 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.
-Taman employer that is providing workers'compensation insurance for my employees Below is the policy andjob site
information.
Insuxance Company Name:
Policy 4 or Set£ins.Lic.#: Expiration.Date:
lob Site Address; L o City/State/Zip: I)0. Ilk
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 ofMGL o.152 can lead to the imposition of criminal penalties of a
fine up to$1,50 0.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fang
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the OfCxco of-
Investigations
fInvestigations of the DTA for insurance coverage verification.
X do Hereby certunder the pains and penalties ofperjury that thein•formation provided Bove is true and correct. -
Si atare• Date:
Phone#•
Official use only. Do not write in this area,to be completer)by city or town off
City or Town: Perri t/License#
Issuing Authority(circle 6ne):
1.Board of Health 2.]Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other - - -
Contact Person: Phone i#:
Information and Instructi
ons
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 ofhire,-
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 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 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 p ermit to op erate 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 of public work until acceptable evidence of compliance with the insurance
requirements of this chapterhave beenpresented 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 numbers)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,apolicyisrequired. 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 thepermit 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:):' copy of the affidavit that has been officially stamp ed or marked by the city or town may be provided to the t
applicant as Proof that a valid affidavit-ii on file for future permits or licenses. .A new affidavit mast 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 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,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
Tho.Cmmon ea tea of Yassarhu�Plte
JDopaftout ofTl dwtdal Aceideits
• Qf�tc�oflu�esti�a�Qx� '
600 Was g&m Strut
Boston,MA021X1
tel#61M-21 ,4900 QA 406 ox 1-•877•-MAFF,
Revised 5-26-05 `ay,0 617"727'7749
�. ;COMMONWEALTH OF MASSACHUSETTS.::
ELECTR I Cil ANS-
ISSUES :THE FOLLOWING LICENSE W ,
AS A REG JOURNEYMAN. ELEETRIC ANS ,
\,
MICHAEL F MACDONALD. %� +
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cn
et, �W t
P0; BOX 8062
HAVERH I LL MA 01835 056.2 § {
$ I
177
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MONWEALTH OF MASSACHUSETTS,
x40ARD OF �{i
>. ELICTftICIANS
f..SSUES, THE, ;FOLLOWING L I CENSE AS A
R�GIS7:I=RED MASTER E:LE�R�,hC
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BRIMAG ELECTRICAL SERVI CES''` `
M1 CHAEL f MACDONALO
.0
PO B:DX 8062
HA'.VERHILL ::. MA
-051-2
018356
16, 0 620 r