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HomeMy WebLinkAboutMiscellaneous - 1532 SALEM STREET 4/30/2018 1532 SALEM STREET :T 210/106.A-0091-0000.0 i a ' o Date................`.......... .. 1 gORTN TOWN OF NORTH ANDOVER PERMIT FOR WIRING �Y,SSACNUSE� This certifies that ........1... . �,✓r,�.�,,�.�,.,- ��1..... has permission to perform .. �....`:`'....... �tf 1 ...............:.. wiring in the building of '?:. :P--'.................................................... at '.... ... ��::� - ...: -r........... ,NorthAndover,.Mass. �� ..... Lic.No.! 0920 Fee:............� ............... .. ECTRICAL IN;WMR Check w--a-5- 8827 0; ' Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked .� � [Rev. l/07] ]eaveblank 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 INF ORMATION) 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) ��j €a�t✓ Owner or Tenant T t\n. ,L Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building S,641ic.e 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: ' F Completion of the o-owin 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 Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency ig g grnd. rnd. BatteryUnits J No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No..of Detection and InitiatingDevices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number_ Tons_ KW- No.of Self-Contained ,► p Totals: Detection/Alertin Devices No.of Dishwashers Space/Area Healing KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* _ No.of Water No.of No.of Devices or Equivalent o. Heaters KW ofSi Zyns Ballasts . Data Wiring: No.of Devices or Equivalent No.Hydromassage Bathtubs No.of MotorsTotal gp Telecommunications Wiring: OTHER: No.of Devices or Equivalent f 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 Stark 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 roof of liability insurance including completed operation"coverage or its substantial equivalent. The undersigned certifies that such covea is in force, and has exhibited proof of same to the permit issuing office.. CHECK ONE: INSURANCE Ef BOND ❑ OTHER ❑ (Specify:) I certify,under the-.w, and pe aloe of perju t the in ormation o Phis a lication ' true and complete. FIRM N S 8 rytf i l i �,6 Licensee: g r LIC.NO.: _(/U.1! Signure LIC.NO.:`�0(If applica e r"exe�g t"in the license number ine.)Address: D. d 0 SL l � /U . �l© �0' � �c!>�/S us lt.Tel.No.: ' Alt.Tel.No.:P eJ4 74 RF— *Per M.G.L c. 147,s.57-61,secunty work requues 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 Signature Telephone No. PERMIT FEE. $1—� r The Commonwealth of Massachusetts l Department of Industrial Accidents c ` Office of Investigations . Itiil' 600 ff ashington Street Boston, MA 02111 www ov/din .mass.g Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant InformationPlease Print Legibly Name(Business/Organization/individual):_4�2/j r, .&/fir 6' ! s1 e^L tr— Address:_ P O, /1 -5, City/State/Zip: A10. i Ooot«^ 01V4 Phone #: . -7� Are you an employer?Check the appropriate box: Type of ' (required): P 1.El 11 ro1ectreq ( am a employer with 4. ❑ I am a general contractor and I � 6. ❑New construction 21 employees(full and/or part-time).* have hired the sub-contractors 2.t11 am.a.sole proprietor or partner- listed on the attached sheet.t 7• F7 Remodeling ship and have no employees These sub-contactors have 8. Q Demolition working for mein any capacity. workers' comp.insurance. g, ❑Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its 10. ectrica]repairs required.] officers have exercised their �_ rep us or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I l.❑ Plumbing repairs or additions myself, [No•workers'comp, c. 1.52, §I(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' comp. insurance required..] 13.❑.Other 'Any applicant that checks bore#1 must also fill out the section below showing their workers''compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. '. �Contmctors that check this box must attached an additional sheet showing the creme of the sub-contractors and their workers'comp.policy information. I ant an employer that is.providing:workerscompensation 4fasurancefor nty.employees: Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach h a co of the workers'. PYcompensation Pe policy declaration page(showing the policy number and expiration date Failure to secure coverage as required under Section 25A of MGL a 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 pa' an pen s perjury that the information provided above is true and correct. Si Date. _ p Phone#: Official use only. Do not write in thisarea,to be completed by city or fawn 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 nurr►ber.listed below. Self-insured companies should enter their self-insurance-Iicense 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 NvilI 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 indicatingcurrent 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel.#617-727-4900 ext 406 or 1-8.77-MASSAFE Fax#617-727-774 Revised 5-26-05 www.mass.gov/dia