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Home My WebLink AboutMiscellaneous - 1260 SALEM STREET 4/30/2018 1260 SALEM STREET 210/106.A-0186-0000.0 ` 1 1� Date... a/ oR'rof TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING SAC This certifies that ........... ...... ....................... has permission to perform ..... wiring in the building of............. ............................................... at....12-&o North Andover,Mos. .............................. . .....:5,; ..........................I.. ?S- va- Fee..................... Lic.No./.7*/*7,2-4.............. ...... EcrRwAL INSPECibR Check # --7-P 8 Tt,. Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No.—F7, BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/071 Qeave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 W r y OR K (PLEASE PRINT INIAW OR 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 perform the electrical work described below. Location(Street&Number) Ia&O <� Owner or Tenant QN q I e I'^ eJA pt Telephone No. Owner's Address M_7 Is this permit in conjunction with a building permit? Yes Purpose of Building I'll ` ❑ No (Check Appropriate Box) Utility Authorization No. &�0�"30f � Existing Service pp Amps 410 / �aoVolts 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: r w On bh e-� Scac f�-e z pti t r r14- P�c `meg Com letion 'the ollowin table m be waived by the Inspector of Wires. No.of Recessed Luminaires No.of CeiL-Sus No.of Total gs.(Paddle)Fans Transformers KVA No.of Luminaire Outlets. No.of Hot Tubs Generators KVA No.of Luminaires Swimming pool Above ❑ In- o. o mergency ig 3End. d. 11 Battery Units —. No.of Receptacle Outlets No.of OR Burners FIRE ALARMS No.of Zones 1 No.of Switches No.of Gas Burners No.of Detection and No.of Ranges No.of Air Cond. Total Initiatin Devices Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number ons KW No.of Self-Contained Totals: ~__..__.._.._ __�_._..... __.__..__._. Detection/Alertin o,Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* - No.of Water No.of No.of Devices or E uivalent Heaters KW Si s gaIlasts Data Wiring: No.Hydromassage Bathtubs No.of Motors No.of Devices or,Equivalent Total HP No. Wiring; OTHER: No.of Devices or E uivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) f Work to Stark i Q Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE v RAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless ! the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the ains nd alties o p ) (f�� P perju. that the information on this application is true and complete. FIRM NAME: FOV e G , r LIC.NO.: Licensee: ; y& r Signature (If applicable, enter "exempt"in the license number 1' e.) LIC.NO.: `7 9 _ Address: t� a�e r<r� D to f Bus.TeL No.: *Per M.G.L c. 147,s. 57-61,security work requires D A „ „ Alt:Tel.No.: ep ent 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 El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ Aft The Commonwealth of Massachusetts k� ! Department of Industrial Accidents Office of Investigations 4)iif+ 600 Washington Street Boston, MA 02111 { : www.massgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le�ibl Name(Business/Drganirdtior individual);—?$�BK a L Address: S e City/,State/Zig: vzp . 1M Phone #: Are you an employer?Check.the appropriate box: F 1.❑ I am a employer with 4. ❑ I am a general contractor and I Type of proles(required): employees(full and/or part-time),* have bred the sub-contractors 6• ❑New construction 2.K I am a.sole proprietor or partner_ listed on the attached sheet.# 7• ❑Remodeling ship and have no employees These slab-contractors have 8. C1 Demolition working for me nl any capacity. workers' comp.insurance. comp, insurance 5. 9• Building addition [No workers' p ❑ We are a corporation and its required.] officers have exercised their 10•0 Electrical repairs or additions 3.❑ i am a homeowner doing all work right of exemption per MOL 1 I.❑ Plumbing repairs or additions myself. [No•workers'comp. c. 152, §I(4),and we have no 12. Roof insurance required.]t employees, ❑ repairs • (No workers' I3.[]Other comp. insurance required.] "Any applicant that checks bolt#l must also fUl out the section below showing their workers'compensation policy in t Homeowners who submit this affidavit indicating they are doing all work and then hire outside conuactors must submit a new affidavit indicating such. lcontnutors that check this box must attached an additional sheet showing the name of the sub•conttwtms and their wortxrs'comp,policy information. arc an er-r-yer that is providing:workers 9 compensation insurance for nv employees: Below is the policy and job site 1 information. Insurance Company Name: Policy#or Self-.ins.Lie.#: Expiration Date: Job Site Address: City%te/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 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 Investigations of the DTA for insurance coverage verification. I do hereby cert nder the pains andpe f perjury that the information provided above is true and correct— Signature: orrectSi ture: Date: 11 J A ` Phone#: 7 g" r_0`F 9 2— t�cial ase 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 enfloyer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or mom of the'foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver ortmstee 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 focal(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 evidencea-t 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)acid 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 empioyees,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,notthe Department of Industrial Accidents. Should you have any questiomregarding the law or if you are required to obtain a workers' c compensation policy,please call the Department at the number listed below. Self-insured companies siiould enter their self insurance license*lumber 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-cm-rent 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 fixture permits or licenses. A new affidavit must be filled out each year. When 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 Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel.# 617-7.274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax 4 617-727-7749 www.mass.gov/dia