HomeMy WebLinkAboutMiscellaneous - 218 LACY STREET 4/30/2018C)
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Date.1-0- --36-de
..........................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .... M1)..C1.41*1.,e .... i��"7
........ ...............................
A,)7 -4,C-7- IA44---7-
has permission to perform .......... ............. t4 ....................................................
wiring in the building of7
.. .................. I ............................................................
at .... �M .... . ................................. ... ;Nort h Andover, Mass.
Fee..,:3-�7—.. Lic. No.,�'7'K-'>T . .........
..... LPAL i�SP �MR
ELE
Check #
8544
Commonwealth of Massachusetts Official Use Only
IFDepartment of Fire Services Permit No. 115-4/
BOARD OF FIRE PREVENTION REGULATIONS 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 M C), 527 MR 12.00
(PLEASE PRINTMINK OR TYPE ALL INFORMATION) Date: 30 j
City or Town of: NORTH ANDOVER To the Inspecto of Wires:
By this application the undersigned ves notice of his or he intention to perform the electrical work described below.
Location (Street & Number) `s l ��1l ( 7.
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit?
Purpose of Building��
Telephone No.
No ❑ (Check Appropriate Box)
Utility Authorization No.
Expsting Sernc&,APs /t olts Overhead ❑ Undgrd ❑
New Service Amps / Volts Overhead ❑ Undgrd ❑
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
No. of Meters
No. of Meters
uG...I y uesirea, 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 proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such c ve ge ism force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
P fi':)
I certify, under the aims and p nal 'es of perjury, that the information on this application is true and complete.
FIRM NAME: C �/ /1//S /C
LIC. NO.:
Licensee:
/1AIA0 Signature
(If applicable, "exempt ' in the h nse numb r h e.) LIC. NO.:
Address: 20 f Bus. Tel. No.: /
*Per M.G.L c. 147, s. 57-61, security work requires Departznent�if Public Safety "S" License: Alt. TelLic. 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 F-1 owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE. $
The Commonwealth of Massachusetts
4' 1 Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
{ j www.mass.gov/dia .
Workers' Compensation Insi once Affidavit: Builders/Contractors/Electricians/Plumbers
�_-i--
Name (Business/OrganiratioMndividual):
Address:% Zc--1�7 -G r — G� 7
City/State/Zip: Phone 441
Are you an employer? Check the appropriate box:
1.
1 am a employer with
4. ❑ I am a general contractor and 1
employees (full and/or part-time).*
have hired the sub -contractors
I am.a.sole proprietor or partner_
listed on the attached sheet. �
ship and have no employees
These su&contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp, insurance
5. ❑ We are a corporation and its
required_]
3. ❑ 1 am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself. [No -workers' comp.
c. 1.52, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required_]
3-�, /o 7s
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
S. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
1 1.0 Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
-r+ ••w^• ��• —. ot. ff � mus< also nu out the section below showing their workers' compensation policy information
t ontrac Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
�Conttactors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, po!ic; inwt—t,ation.
I am an employer that is providing:workers' compensation insurancefor my employees;
information. ,, _ ., Below is the policy and job site
Insurance Company
Policy 4 or Self -ins. Lic. #: Expiration Date: ��� .
Job Site Address: City/State-/Zip:
Attach a copy of the workers9. 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 gal the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations of the I oinsut•ance coverage verification.
I do her eb�c rti n` e p and penalties of perjury that the information provided
I Si a re: Date•
Phone t U
Official use only. Do not write* this area, to be completed by city or town official
City or Town:
_ Permit/Licease #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
is trove and correct
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 timstee 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 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 cant' 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, nofthe 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 numberlisted below, Self-insured companies should enter their
self-insurance license number on the appropriate tine.
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 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
Revised 5-26-05 Fax # 617-727-7744
www.mass.gov/dia