HomeMy WebLinkAboutMiscellaneous - 146 MAIN STREET 4/30/2018 (4) 371 Niq g'
Date............... .. ...................j
OF NORTIy,~C
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
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This certifies that
......................... ..................................................................
has permission to perform ...... .F'.C'�..SSP.Q t1.... r. .1........
wiring in the building of.........
at ..... ....?.`l .... '.^-......-% ...... ..,�t........... ..../&orth Andover,Mass.
Fee..(..�j-...�.......Lic.No!��—�� joa-� `..f. ::.//�....................................
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4//e�� ELECTRICAL INSPECTOR
' Check# 1 � /�"
-� 6
l,om.monwealth o///'/abdac4uJe Official Use Only
' c�00 Permit No. Z-`{'e-)
2eparttmentt o f Sire Services
BOARD OF FIRE PREVENTION REGULATIONS 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(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: July 16, 2015
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) 146 Main Street- 2nd Floor Tenant Space
Owner or Tenant GSD ArchiteCtS Telephone No.978-836-2264
Owner's Address Same
Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box)
Purpose of Building Office Building 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: Install Recessed Lighting, Switches and Outlets.
Completion of the following table ma be waived by the Inspector of Wires.
No.of Recessed Luminaires 41 No.of Ceil:Susp.(Paddle)Fans o.of Total
.Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool_Xbove ❑ n- ❑ o.o Emergency Lighting
rnd. rnd. Battery Units
No.of Receptacle Outlets 10 No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches 8 No.of Gas Burners No.o Detection and
Initiating Devices
No.of Ranges No.of Air Cond. TotalTons No.of Alerting Devices r
No.of Waste Disposers eat Pum umber Tons No.o elf-Contained —l-
Totals:P ............................................ Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ unicipal ElOther
Connection
No.of Dryers Heating Appliances KW ecurity ystems:
No.of Devices or Equivalent
No.o Water KW Signs
of o•o Data Wiring:
Heaters Si s Ballasts No.of Devices or Equivalent V7No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wirmg:
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: $3,000.00 (When required by municipal policy.)
Work to Start: 7/20/2015 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 N BOND ❑ OTHER ❑ (Specify:)
I certify,under thepains and penalties of perjury,that the information on this application is true and complete.
' FIRM NAME: High-Tech Electrical Contractors, Inc. LIC.NO.: Al 1889
Licensee: Michael J. Pallazola Signature LIC.NO.: E28416
(If applicable,enter "exempt"in the license number line) Bus.Tel.No.: 978-768-7322
Address: 239 Western Ave. Essex Ma. 01929 Alt.Tel.No.: 978-768-3520
*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 $ S
Signature Telephone No. PERMIT FEE.
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The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
www mass.gov/dia
yV' Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERARTTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): 1-1t i ci L T>° • h at riaG l 6oYl 1-Yna
Address: 3�i wGS f tft� UyC�
City/State/Zip: Fs�,c[ Glg2!a Phone#: -
Are you an employer?Check&e appropriate box: Type of project(required):
1421 am.a.employer with _employees(full and/or part-time).' 7. ElNew construction
2. I am a sole proprietor or partnership and have no employees working for me in 8. E�-Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
IF]I am a homeowner doing all work myself[No workers'comp.insurance required.]t
10 0 Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions
proprietors with no employees. 12.Q Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs
These sub-contractors have employees and have workers'comp.insurance.#
6.Q We are a corporation and its officers have exercised their right of'exemption per MGL G. 14.Q Other
152,§1(4),and we have no.employees.[No workers'comp.insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
I Homeowners who submit flus affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-coniracfors have employees,'they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site
information.
Insurance Company Name: .C,oY,;)
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 1`7 FVIM c 5 i o=k: 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 required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance
coverage verification.
I do hereby certify under the pains and penalties of per jury that the information provided above is true and correct.
Signature: Date: -7'
Phone#
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-contractor(s)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 arerequired to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insur6d 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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel.# 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
oj=COMMONWEALTH OF MASSACHUSETTS
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FSSUES THE FOLLOWING L t-E SE 'AS,,,
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MASTER: ELECTRI:_C:I`ArN i
R I CHARD J LATTOF
15 CLEARVIEW AVE + ' �W
G:LOUCSTERMA 01930 3319
20088 07/3.1/ib: 27903 {
`:COMMONWEALTH OF MASSACHUSETTS ; 1
ELECTRICIANS
ISSUES THE FOLLOWING LICENSE
AS...A RE:CA.0URNEYMAN. .f LECTl21.,C.I,:AN ¢ j
RICHARD J LATTOF JR ,, r i;
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15 CLEARVI EW AVE
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