HomeMy WebLinkAboutMiscellaneous - 10 WOODRIDGE DRIVE 4/30/2018 (6)r
Date ....1.z.."...� U.."...7
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
c �91i►�1 S o
This certifies that......................�..............................................................................
has permission to perform .............. ............................................ ....................
wiring in the building of ............./!!.../��..:....7 .....................................................
at ..P ...... w ........... 0 _0/ /� orth Andover, Mass.
................ . �l ..:..
Fee...--.... Lic. No..�.�Q.M�...................1............, �..:
ELECTRICAL INSPEC OR /
Check # __��
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Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. / 30290
Occupancy and Fee Checked
[Rev. 1/071 leave blank
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 WINK OR TYPE ALL INFORMATION) Date: C/ 7 /
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) /0 wd 46,.C(f.P
Owner or Tenant S4 Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building A i? 5 - 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: & 4A j6 t2 A� ,.N
Completion ofthe 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 Luminalre Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑In- Elo.
rnd. rnd.
o mergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burgers
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Number
"
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 Wires.
Estimated Value of El e trical Work: (When required by municipal policy.)
Work to Start: /W/7 IV Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE C VE GE: 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, ander th of andpenalties ofperjury, that the information on this application is true and complete. _
FIRM NAME: O0 4 LIC. NO.: .2 � 13 9 t
Licensee: Klc. - ct. is Signature LIC.NO.: t176 141..
If
( applicable, enter "exempt" in the license number line) - Bus. Tel. No.: 6b3 a 3/ 7y,SI -7
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 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.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance.with the provisions of M.G.L. c. 143, § 3L, the p
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 V
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❑'
Failed (]
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass R
Failed ❑'
Re- Inspection Required ($.) ❑
Inspectors Comments: .
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass N
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments: 11
Inspector Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com
j
The Commonwealth of Massachusetts
Department of Inrltcstriccl Accielents
Office of Investigations
600 Washington Street
.Boston, MA 02111
www.mass.gov/rlia
Workers' Compensa€ionbnsuranceAfrdayff: BuffderslContractors/Electricians/Piffi burs
A.ppllican lnforanaiion Please Prtu Le2lbly
Name (Business/Organizaiion/.fndividual): C -moi `"C+ Gof1 q Sy
A6 3g y Phone #• 6CS . j / 7 � %
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4. ❑ I am a'general contractor and I
mployees (fall and(or Part-time).* have lifted the sub -contractors
2. L14 I am a sole proprietor or partner- listed on the attached sheet.
ship and'haveno.employees
working forme in any capacity.
[No workers' comp. insurance
required.]
3. [J I am a homeowner doing all work
myself. [No workers' comp.
insurancerequired.] i
These sub -contractors have
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised.their
right of exemption per MGL
c.152, §1(4), and wehaveno
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New contraction
7. 4emodeling
8. [l Demolition
9. ❑ Building addition
10.0 Electricalrepairs or additions
1111 Plumbingrepairs or additions
12.❑ Roofrepairs
13.❑ Other
x.Any applicant that checks box#1 must also fill outthe section bel6w showingtheir Workers' compensationpolicy information.
i Homeowners who submitthis affidavit indicatingthey C"re dping allwork and then hire outside contractors must submit a new affidavit indicating such.
?Contractors that checkihis box must attached midditional sheetshowingthe name of the sub -contractors andtheirworkers' comp. policyinformation.
lam an employer that is providing Workers' compensation insurance for my employees .Below is the policy and job site
information.
Insurance Company
Policy 4 or Self ins. Lie.
RTItationDate:
Job Site Address: City/State/Zip:
,Attach a copy of t ie workers' compensation-polley declaration page (showing the policy number and expiration date),
laiiure to secure eoverage.as reguired.under Section 25A ofMGL e. 152 can lead to the imposition of criminal penalises of a
- fmo 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.
X do liereby & u der• iliepains and penalties q f perjury Mat fixe information;provided above is true and correct.
SiPnature ce _ U. ����+� Date: l.Z/ /Z 4i y
Thone #• E,� 3 ;2,3 / 7 9�� 7
Official arse ortly. Do not write in this area, to be completed by city or torus 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 Terson: Phone 0:
Information and Instruction's
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for Their employees.
Pursuant to this statute, au 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 ox more
of the foregoing engaged in a joint enteiprise, and including the legal representatives of a'deceased emplothe
redeiver ortrr stee of as individual, parhiersbip, association or other legal entity, employing emyer, or ployees. IZowevethe
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 .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 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
aiecessary, supply sub -contractors) name(s), address(es) andphonenumber(s) alongwiththeir certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are notreq*ed to cany workers' compensation insurance. If an LLC orLLP does have
employees, a policy is required. Be advised that tbis 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. Shouldyou 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 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 fits in the permit/license number which will be used as a reference number, In addition, an applicant
that must submit multiple permit/Rcense applications in any given year, need only submit one awavit indicating curxent
policy information (ifnecessary) and under "J'ob Site Address" the applicant should write "all locations in (city or
town:)." A: copy of the, affidavit thathas been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid af�davit.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 �
0.a. a dog license or permit to burn leaves etc.) said person is NOTrequired to complete this affidavit,
The Office of lnvestigations would like to thank you in advance fox your cooperation and shquld you have any questions,
please do nothesitite to give us a call, .
The Department's address, telephone and flax number:
Tho GQx onwaaltlz of mgrlivsPiis
Departmoat Qf 11 dusirial,Accidonta
Wrice ofIntyestigatiow
6b0 Wasbiugtaxr• Street
Boston, NA02111.
` e,1, 9 617-727-49QQ ext406 Qx x-877.:1V�ASSA
Revised 5-26-05 6 �4
w�vtr.�ass,g¢vErctia
Date.G. . . . ..............
OF T
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies
.04 ................................
has permission to perform
winng in the building of ....................................................................
at AD ....... �.(?�,46. ...... C4..................... North Andover, Mass.
Fee Lic. Noe
L
i(TRICAL INSPECTOR
Check#
2 7
V. .
r
BOARD O,F FIR -E PREVENT_ [0N REOULFt'
c-onfi act � & bfclg�F7Yira � Ia a1�plioaGlE 1 �
APPOG� ATWN FOR PERMIT TO PERF0 RM ELECTRICAL WORK
,U wodCio hepezfornedlu accordaocew a iha Nlass4usoffsBlec4frai Code a ECZ 521p2 32.00
(PI4,5`� PRLN'('1N 1NXOt 2� [0 TION] Date:_
City or Form of ��f f d (a1�� 'o the Irzspec�ot of F�i� es:
By thisapplicatfottzheunderignedg?vesnoiic of3vsoffherinfe ao topeziormthe eleafriGalvtorkdescirbcdbelov:'
Locafforr(Street&-N, tuber)
Omar or'Iwaire !J'ff kfo� TelepTX0noND,
€7wnea's Address
S th s pexmif iu coaf uactioaz �tiflt a bru7dingpernirE? Fest ❑ 117a (fiecic frppropriaf�$o}
Burpose of Building - IJ'iiIify Au Itorizafiott 11To, .. .
Bxistittg Be?-fioa Amps / Vo%- E3verhead ❑ . Uttdgrd. �� . _ .No. aP1VCefers
Ney7 Seiyice: Amps. 1 dolts Overheao: ❑. Undgrd ❑ 1Ta, ofl4rCeters
IN um er o ieedersAndlsmpadiiy
LooaiiozzatdNaiuraofPraposedElect�icalWork: Li,5/_rz„ Ac- IW6/ 5t3s"Jel-,
�U AschadditEvnalcLtnirifdesired orasreg4-e¢byae-InapectcrafWrres: i
BsdmatedY2iueofBle 'cal�Ygrk-,V )/rte (Y,;ueo regazedbymunicipa?pelicy}
r worktn SiaziI�specfions to beraquesfediaaceordan_ce wit%TYBC Bila 10, and upon completion,
IhISMANCD C0 GIs: UnIess waived by the oveuer, m perraitfor the p6rzolmuce of elecaical work may isste unless
ihelicenseepratidesproofbifiability;nsacanceineiudng complaiedopEr ion"covezagaorifisubsr� alegvTvzTeA4 The
�nndarsfgned cezOm the stub, coverage is in force, and has exbibitedproof of sAme to tho pe='r- is -sung office.
CHECK07q�,?; 3NSU3LNCB j] BOND ❑ OTHER n (Spod6l:) Self -Te=ed
..I"cet�ifjj,. r�-rider f1tepai� a�idpenrriiTes' ofperjrrrJ', th¢itrz� r����. O� ifzis ¢p//tcaiiG� is true erz4%rtCOx�T2pLeiee
i's_'.`MWAM: A -D LLCDBy1tx1-TSecv C.Y f r7l / rTL.I�€�,: 0-172
Licensee: lRomas T..I ea ignzfure BIC.1`IO.: C-172
pfapplicable. �r "P7emoi'' inehe 11 e number l ne.I �� Bus. TeL No,t
ddresst ��1 � i�r ld i r`5 �Ef/ f7E ila;ri Alt Te1,1�tb.:6-oa - z �_ �`� 2 6
Y�e=fiy System Cont adorLiceuse required fox this worst; inapplicable, em 001779
OWN. -6 lS]W,SUl:ZANCNWAMR-- Imnaw' arothafw.eficmnseedoesnothavetheliabiIryinsurmorcoverapnoimaUy
required by Taw, By my signaimc below, I hereby waive this mqukomeut. I ammo (check one} Q owner [j 0 -vases agent,
€)h' er/agent .4—IT � S�
Signature Telephonao,
CorV retlan of the folrovinp {able may be waived by the Inspector of Wires.
o�f�sec �r3nairc�To'nf-Ceil.=5usp_�,liaU
lYo. of 'TofaZ
. axtsiaxpzers--1��
lefs
m. oEiz�l
No. of Hot Tubs
Umekafors KVO•
.No. o
Above Itz-
Swimmiug 'aoI ted. � d.
o. o meru&Acy J-ig rug
Q Bafte 17�nifs
— sir 9I r=qfl F-=�E@� —
�
_—�' SA=T 1if'�; -: 41.=Q2r-7_,9-a€r-IN6,
of r°as?3m-mrs
o, oxvetection and
Iultiatiu Deviees
No,e
l�'o..of�irConcL Pons
Na. ofAleridngl evices�. -_:�; r/t
N,2. of ` vrashe Disposers
$e Tnt sp
1Yuu3ber Taus E Yd
QDefecfion/Aio. a n a TseYices`
Iro,OfDishwashers
S.pace/AreaMat_ing T
ZotaI[] Mrm3cipai � ot3ier
CoA2tee on
lib. of Dryers
HeafingApplf pees I
Sec ofpevier� or alenf
11To. of Water
Heaters
NO. of JNO. of
+ signs Baiasts
Dafa �y�g;
No. of Devices or E u valent
p o.HpdromassagapatTifubs
a140. of112ofors °I`oWIT
Telecommunications Wixing:
No. 006vices o T uiYaient
cZma-a�•v_ '
'
�U AschadditEvnalcLtnirifdesired orasreg4-e¢byae-InapectcrafWrres: i
BsdmatedY2iueofBle 'cal�Ygrk-,V )/rte (Y,;ueo regazedbymunicipa?pelicy}
r worktn SiaziI�specfions to beraquesfediaaceordan_ce wit%TYBC Bila 10, and upon completion,
IhISMANCD C0 GIs: UnIess waived by the oveuer, m perraitfor the p6rzolmuce of elecaical work may isste unless
ihelicenseepratidesproofbifiability;nsacanceineiudng complaiedopEr ion"covezagaorifisubsr� alegvTvzTeA4 The
�nndarsfgned cezOm the stub, coverage is in force, and has exbibitedproof of sAme to tho pe='r- is -sung office.
CHECK07q�,?; 3NSU3LNCB j] BOND ❑ OTHER n (Spod6l:) Self -Te=ed
..I"cet�ifjj,. r�-rider f1tepai� a�idpenrriiTes' ofperjrrrJ', th¢itrz� r����. O� ifzis ¢p//tcaiiG� is true erz4%rtCOx�T2pLeiee
i's_'.`MWAM: A -D LLCDBy1tx1-TSecv C.Y f r7l / rTL.I�€�,: 0-172
Licensee: lRomas T..I ea ignzfure BIC.1`IO.: C-172
pfapplicable. �r "P7emoi'' inehe 11 e number l ne.I �� Bus. TeL No,t
ddresst ��1 � i�r ld i r`5 �Ef/ f7E ila;ri Alt Te1,1�tb.:6-oa - z �_ �`� 2 6
Y�e=fiy System Cont adorLiceuse required fox this worst; inapplicable, em 001779
OWN. -6 lS]W,SUl:ZANCNWAMR-- Imnaw' arothafw.eficmnseedoesnothavetheliabiIryinsurmorcoverapnoimaUy
required by Taw, By my signaimc below, I hereby waive this mqukomeut. I ammo (check one} Q owner [j 0 -vases agent,
€)h' er/agent .4—IT � S�
Signature Telephonao,
rF
l01iJ'� G� o Yin 0IMMUL t. ,
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Commonwealth of Massachusetts
Department of Public Safety
Sccurily S1 Ift ms- S- Ncen%r
License: SS -001779
Thomas d Lee
410g7n9versity-Ave; r3= ` *' 'A
Westwood P/�0209Qr ' : =��
Expiration:
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Commissoner
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ACS
�._.. ^ CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYYY)
09/25/2013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
Aon Risk services Northeast, Inc.
Morristown N] office
CONTACT
NAME'
INC. No.EXt): (866) 283-7122 FAX
No.): (800) 363-0105
E-MAIL
ADDRESS:
44 Whippany Road, Suite 220
Morristown N] 07960 USA
INSURER(S) AFFORDING COVERAGE NAIC #
INSURED
INSURER A: Zurich American Ins CO 16535
ADT LLC
INSURER B: American Zurich Ins CO 40142
ADT Security Services
INSURER C:
1501 YamatO Rd
Baca Raton FL 33431-4408 USA
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 570051395419 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as requested
INSR
LTR
TYPE OF INSURANCE
ADD
INSR
SUBR
WVD
POLICY NUMBER
POLICY EFF
MMIDDIYYYY
POLICY
NM/DDIYYYY
LIMBS
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE Fx_1 OCCUR
GLOS $
EACH OCCURRENCE $2,000,000
DAMAGE "'HEN TED $1,000,000
PREMISES Ea occurrence
MED EXP (Any one person) $10,000
PERSONAL& ADV INJURY $2,000,000
GENERAL AGGREGATE $4,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
X POLICY M PRO- LOC
PRODUCTS - COMP/OP AGG $4,000,000
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOS NON -OWNED
AUTOS
COMBINED SINGLE LIMIT
BODILY INJURY ( Per person)
BODILY INJURY (Per accident)
PROPERTY DAMAGE
Per accident)
4DUMBRELLA
LIAB OCCUR
EXCESS LIAB HCLAIMS-MADE
ED RETENTION
EACH OCCURRENCE
AGGREGATE
B
A
"
'f
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR / PARTNER / EXECUTIVE ❑
OFFICERIMEMBER EXCLUDED? N
(Mandatory in NH)
yes, describe under
DESCRIPTION OF OPERATIONS below
N I A
wc509589701
WC509589801
10/01/2013
10/01/2013
10/01/2014
10/01/2014
WC sTATU. I orH-
X TORY LIMITS ER
E.L. EACH ACCIDENT S2,000,600
E.L. DISEASE -EA EMPLOYEE $2,000,000
E.L. DISEASE -POLICY LIMIT $2,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
CERTIFICATE HOLDER
CANCELLATION
`m
0)
O
Z
d
R
w
zEo)
U
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE ti -
POLICY PROVISIONS.
TOWN OF NORTH ANDOVER AUTHORIZED REPRESENTATIVE
INSPECTOR OF WIRES J
124 MAIN ST.
NORTH ANDOVER MA 01845 USA
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
Date ......
+l NcwrN
3r � TOWN OF NORTH ANDOVER
w +
PERMIT FOR WIRING
�88+c►+U
This certifies that ..........
....................................................................... .......................
has permission to perform ..... ..................
wiring in the building of..,,.,1 .(.,r S -t. ! �2 /4�
................ .......................... ..........................
P ....t���.........� �� .. ..5'..t .. ...... ...........................1,� North Andover, Mass.
`
Feeq.Q ................... Lic. No....�... ...... �!A...................��.......................' . ............
ELECTRICAL INSPECT
Check #
11772
a'
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official IUse Only
Permit No. 1 1 7
Occupancy and Fee Checked
[Rev. 1/07] (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 PRINTWINKOR TYPE ALL MFORMATION) Date: SI -7113
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of s r her i4tention to perform the electrical work described below.
Location (Street & Number) �� f.- c dbr id -i e %�aL
Owner or Tenant Vq Vt
Owner's Address
d' <S Quh F AA q &I Telephone No.
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service Amps / Volts
New Service Amps / Volts
Fn IC
Yes
No ❑ (Check Appropriate Box)
Utility Authorization No.
Overhead ❑ Undgrd ❑
Overhead ❑ Undgrd ❑
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: fLr` c� �G� D►1b
No. of Meters
No. of Meters
Completion ofthe 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 LuminairesSwimmin
(v
Pool Above ❑ In- ❑
g rnd, grnd.
o. o Emergency Lighting
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. Tons Tot
No. of Alerting Devices
No. of Waste Disposers °
Heat Pump
Totals:
Number
Tons
"' ''""' "' "'"""..........
KW
"''
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers f
Space/Area Heating KWLocal
❑ Municipal ElOther
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or E uivalent
rr
OTHER:�ec2f'�-
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: of CoM 6?' (When required by municipal policy.)
Work to Start: # j 3 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 cove ge is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify)
I cert, under th pains and p nalties of perjury, that the inforntatlo on this application is true and complete nn
FIRM NAME:. 5 e(� ci`� Com- LIC. NO.: IL
Licensee: �C, Vbl r Signature44
LIC. NO.: 6
(If applicable, enter "exempt" in the license number line) Bus. Tel. No.: Gd; a�7
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 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.
❑ 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, fine 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 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass n
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
i
Pass n
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INP TION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Com ts:
- q
ILL Y41=
/ .-
Inspectors Signature: V
Date:
FINAL INS E TION:
Pass M
Failed ❑'
Re- Inspection Required ($.) ❑
Inspectors Co gnts
VIA
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Uf www massgov/Zia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeLyibly
Name(Business/Organization/Individual): 5,56
Address: 7 v Ac�lCity/State/zip: (Gi'tLAJS C4, 14- c0 TV Phone it: 6b.3 --231 7V1�
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
pinployees (full and/or part-time).*
have hired the sub -contractors
listed the
7. [Y�Remodeling
2. I am a sole proprietor or partner-
on attached sheet.
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.
9. Building addition
[No workers' comp. insurance
5. El We are 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. [No workers' comp.
c. 152, § 1(4), and we have no
12. ❑ Roof repairs
insurance required.] t
employees. [No workers'
13.❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill outthe section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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:
Policy # or Self -ins. Lic. #: Expiration Date;
Job Site Address: City/State/Zip:
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 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
Jnvestigations of the DIA for insurance coverage verification.
I do hereby /ce � nder thepains and penalties ofperjury that the information provided above is true and correct.
iF9U �o.�
Signature: ���t�f' Date: � 1 _r/ / 3
Phonet CO3.23f 7TY2
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 #:
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 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.
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 Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investiigations.
600 Washington Street
Boston., MA. 02111
Tel. ## 617-727.4900 ext 406 or 1.-877,MASSAFE
Revised 5-26-05 Fax## 617-727-7749
wwv�.mass,go�fdia
Date .... ........
A
TOWN OF NORTH ANDOVER
IL
PERMIT FOR WIRING
This certifies that...'/ .......... ..... ..............................................................
U
has permission to perform .......
Gwiring in the building of ... ...• .......... ...........
at.................................. ............................ . North Andover, Mass.
Fee ..................... Lic. No...,/ .............
CTRICAL� iSP;EcTOR
Check # a-3` &
9322
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 constmction activity, and maybe_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 effector existence" during the qualifying period beginning on August 15, 2008 and extending'through August 15, 2012.
Rule 8—Permit/Date Closed: /S ***Note: Reapply for new perm'
=�
❑ Permit Extension Act — Permi /Date Closed:
0
Commonwealth of MassachusettsFOccupancy
Official Use Only
Department of Fire Services a
BOARD OF FIRE PREVENTION REGULATIONS nd Fee Checked
neave blank
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 WINK Op TYPE ALL INFORMATION) Date:
City or Town of: NORTH ANDOVER
To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perthe electrical work described below.
Location (Street & Number) �� 1'ocXer)12
Owner or Tenant
a o .�
Owner's Address C tAMt?
Telephone No.
Is this permit in conjunction with a building permit? Yes
in�(� ❑ NO ❑ (Check Appropriate Box)
Purpose of Buildg
Utility Authorization No.
Existing Service M fps / Volts Overhead
❑ Undgrd ❑
New Service Amps / Volts Overhead
❑ Undgrd
A ❑
Number of Feeders and.mpacity
Location and Nature of Proposed Electrical Work.
L
No. of Meters
No. of Meters
Estimated Value of Electrical Work:
Attach additional detail if desired, or as required by the Inspector of Wires.
Work to Start (When required by municipal policy.)
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 covfe �a is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE LY BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the informatmn on this application is true and complete.
FIRM NAME: ITS Ekes, VI
Licensee: g�� ptJ L LIC. NO,: 1 '7 �'S/3
4 i�l C £cS�E r Signature
(If applicable, enter ` exempt "in the license mber linea LIC. NO.:
Address: `� �� t 4 41 e-4 Bus. TeL No.: h/t'_3-t($c
*Per M.G.L c I47, s 57-6 secunty work requires Dty Alt: Tel. No.:
OWNER'S INSURANCE WAIVER: I am aware that the L,i�ens e doles, noSaft hav1e'the tliabili Lic. No.
required by law. By my signature below, I hereby waive this requirement I am the (check one) [I owner coverage l] ownerance 's ent.
Owner/Agent
Signature Telephone No.
v
V
No. of Recessed Luminaires
Com letion a the ollowin
No. of Ceil.-Sus p. (Paddle) Fans
table may be waived by the Inspector o_ f Wires.
No. o Total
No. of Luminaire Outlets
No. of Hot Tubs
Transformers ��,
Generators KVA
No. of Luminaires
Swimming pool Above ❑ In-
d. ❑
o. o mergency g
-- , No. of Receptacle Outlets
ad
No. of Oil B users
Batte Units
No. of Switches
ALMS N0. of hones
No. of Gas Biu Hers
No. of Detection and
No. of RangesNo.
of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
eat Pump Number ons KW
Totals: `�
-C
Self
o. of Self -Contained
No. of Dishwashers
Space/Area Heating KW
Deteetio Devices
Local ❑ Municipal
No. of Dryers
o. of Water
g�� A
Heating Appliances KW
Connection ❑ Other
Security Systems:
No. Devices
Heaters KW
No. of o. of
Si
of or Equivalent
Data Wiring:
No. Hydromassage Bathtubs
gus Ballasts .
No. of Devices or Equivalent
No. of Motors Total HP
Telecommunications Wiring:
OTHER:
No. of Devices or Equivalent
Estimated Value of Electrical Work:
Attach additional detail if desired, or as required by the Inspector of Wires.
Work to Start (When required by municipal policy.)
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 covfe �a is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE LY BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the informatmn on this application is true and complete.
FIRM NAME: ITS Ekes, VI
Licensee: g�� ptJ L LIC. NO,: 1 '7 �'S/3
4 i�l C £cS�E r Signature
(If applicable, enter ` exempt "in the license mber linea LIC. NO.:
Address: `� �� t 4 41 e-4 Bus. TeL No.: h/t'_3-t($c
*Per M.G.L c I47, s 57-6 secunty work requires Dty Alt: Tel. No.:
OWNER'S INSURANCE WAIVER: I am aware that the L,i�ens e doles, noSaft hav1e'the tliabili Lic. No.
required by law. By my signature below, I hereby waive this requirement I am the (check one) [I owner coverage l] ownerance 's ent.
Owner/Agent
Signature Telephone No.
v
The Commonwealth of Mmachuselts
Department of industrial Accidents
Office of invesdgations
600 W ashinaton Street
BOston, MA 02111
www trtass.gov/dia .
Workers' Campensation insurance Affidavit Builders/Contractors/Electricians/Plumbers
Aicant Information
- ••.�.. i � Lib 1
Name (Business/DrgsnizaEion/individval):
Address: , I'AnnA_ , rT
City'state/Zip AL)z , O,4 p l $ 3 2 Phone #: CP� Ll 2 3 - Ll ao
Are you an employer? Check.the appropriate box:
1. ❑I '
employer with
4. ❑ I am a general contractor and i
pioy= (full and/or part-time).*
2• I am .a.sole proprietor or
have hired the sub -contractors
luted
partner_
ship and have no employees
on the attached sheet z
These sub -conn acts have
working for me in any capacity,
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
ld-]
3. F1r cin a homeowner doing
offices have
offichave exercised their
all work
n7YseI£ [No -workers' comp.
right of exemption per MGL
c. M § 1(4),'and we have no
insurance require&] t
.employees. [No workers'
corn" instuan irnd-
Type of project (require f�:
6. ❑ New construction
7. ❑ Remodeling
8. Q Demolition
9. ❑ Building addition
10•❑ Electrical repairs a additions
1 I .❑ Plumbing repairs or additions
12.[] Roof repairs
ce requ ] 13.[] .ether I
`4n3 applicant that checks bene (must silo fill out the section below showieg their workers' coin
- T
Homeowners who submit this affidavit isditating they are doing all worst ttsctorors poiecy mfotmahos
4C*n=m tat hcheck this box must areched an additional sheer sho and then him outside comust submit a aew 8fhdpVlt indicating ruck
wing the name of the sub-cottrpe_n� MLA Fes; .
t a►n an employer that is e» �:p. POli�, infimiaiion.
P . C►rg:workers compensation imurm wefor MY e L
. information. mP oYem, Below is tlsePaUcJ' medjab site
Insurance Company Name: '
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address:
CitylState/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date}
Failure to secure coverage as requited under Section 25A of MGL c. 152 can lead to the imposition. of criminal
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 5250.00 a day against. the violator. Be advised that a copy of this statement may be forwarded to the Office a
investigation f t e DIA for ce g verification.
I � — i r
! do hereby y under the enaltiesr'
1 Y that the 0Vormati0n provided above ' true used correct
Si ature:
Phone #:
Date:
offaciat use only. Do not write in this area, to be enraPlered by city or town o cin(
City or Town;
Permif/License #
Issuing Authority (circle one):
I. Board of Health Z. Building Department 3. City/Town'Clerk 4. Electrical Inspector
6. Other 5. Piambiag inspector
Contact Person:
Phone #