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I
j Date........1..'..-01..`:!�.16....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............... ....... r.4......
r
has permission to perform ............. :�>................................................
wiring in.the building of ..........DIV ...... ...................:......
at ....... ' �o.. L e�.1,.!.5 �4kI.......`5";7 .................. . North Andover, Mass.
Fee ... ��.�.—'C'�'""' Lic. No...z.2?. ��.��1...4. ;�.A.-,
...
``''77INSPECTOR
Check #
7951
44'
Commonwealth of Massachusetts Official Use Only
UL Department of Fire Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [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: t I f5a g -
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) Z 4e L i t C o) ti S T
Owner or Tenant (,� 6u C 1 A vvt S -
Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes 19 No ❑ (Check Appropriate Box)
Purpose of Building 644-h � Utility Authorization No.
Existing Service Lc�o Amps 1 Z o/ Zq Wolts Overhead Undgrd ❑ No. of Meters 2.
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity _2 tz _Z_ ZrZ. , ->
Location and Nature of Proposed Electrical Work:
No. of Recessed Luminaires (
..w Jv.w rv..o
No. of Ceil: Susp. (Paddle) Fans
o—X inu uc wal vea by Lne ins ecror of wires.
No. of Total
Transformers KVA
No, of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires 2..
Swimming Pool Above ❑In- ❑
o. o Emergency Lighting
rnd. rnd.
Batter Units
No. of Receptacle Outlets 2
No. of OR Burners
FIRE ALARMS
No. of Zones
No. of Switches 2
No. of Gas Burners
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/
Security Systems:*
No. of Water
KW
No.
NO• of No. of
No. of Devices or E uivalent
Data Wiring:
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or E uivalent
OTHER:
naacn aaamonat aetau �f desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 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 ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains andpenalties o perju , that the information on this application is true and complete.
FIRM NAME: it L e_ �. l� Gr��r LIC. NO.: l 2 3 M R
Licensee: 1A1rr Ll Signature
LIC. NO.: 17 31+t ✓L �
(Ifapplicable ter " empt" in the (ic nse numb dine.) Bus. Tel. No.: leb—92G-303 i
Address: rCb 1Z LZ l� r4-tiv� �O�-or►► t- A-115 1V 4 p'3e 4«f Alt. Tel. No.: b�3 - cl t s - 4059 a
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. 7
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:
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The Commonwealth of Massachusetts
Department of industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
t� s www.nzass.gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Legibly
Name (Business/Organization/individual); �„ ►q wr a y s a -� t< G T) 54 RN", -r, � 1
Address: Pb %36 X tZ Co
City/State/Zip: �Am P�a w �'w- �S �V �{- 0 ifs g 40Phone #:�.b3 g Z 3 d 3 1
Are you an employer? Check the appropriate box:
Type of project (required):
l.I am a employer with
4. ❑ 1 am a general contractor and I
6. ❑ New construction
employees (full and/or part-time).*
2. ❑ I am a.sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet 1
7. ❑ Remodeling
ship and have no employees
These subcontractors have
8. ❑ Demolition
working for mein any capacity,
[No workers' comp. insurance
workers' comp. insurance.
5. ElWe are a corporation and its
g, ❑ Building addition
required.]
officers have exercised their
10.❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work
right of exemption per MGL
11.❑ Plumbing repairs or additions
myself. [No -workers' comp.
c. 1.52, § 1(4), and we have no
12.❑ Roof repairs
insurance required.] t
employees. [No workers'
13 ❑ Other
comp. insurance required..]
-Any applicant that checks bort # I 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.
;Contractors that check this box mustattaehed an additional sheet showing the name of the subcontractors and their workers' comp, policy information.
I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company N
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 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 DIA for insurance coverage verification.
I do hereby cer/tt�y under the pains andpeii�lties ofperjury that the information provided above is true and correct
Phone #: %b,11— C?Z(p - 3 03 I
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
6. Other
Contact Person:
4. Electrical Inspector 5. Plumbing Inspector
Phone #•
Information and Instructions k
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 firture 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 andfax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
