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Date
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...... ................................................................................
12v�'A- 9 C-�'
has permission to perform ........ .............................................. e ......
CC)\ �,- r -e—
wiring in the building, of ..........
........................................................................ 6 ......
at ? ...... it -40'7. -) .1# ....... (.� ................................................. North Andover, Mass.
... .......
Fee.. . .......... Lic. No .......................................................................................................
ELECTRICAL INSPECTOR
Check #
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Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official �Use Only
j
Permit No. 1' '"1-" I
Permit Fee Assigned
11/99]
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
FOR INSTITUTIONAL* USE ONLY
This form is for use by institutions employing licensed electricians and others for which notice of electrical installations to the
municipal Inspector of Wires is required for work on the premises of the institution. If you are not an employing institution
pursuant to C. 141 §8 of the Massachusetts General Laws, stop here. You cannot use this forrp. U e the standard form only.
(PLEASE PRINT IN INK O PE L I FORMATION) Date: r3
City or Town of: CA/e1 To the Inspe for of Wires:
By this application the undersigned gives notice of the on -premises performance of electrical work by employees.
of Proposed Electrical Work:
We will file this form on each such occasion (check one):
We will maintain one or more contemporaneous log(s) (check one):
This option is available where so contemplated by the municipality.
and upon significant changes in employment.
NO ❑
YES ❑ NO 0
In these cases, you must renew this application annually,
The following individual(s) will be responsible for the accuracy of the log(s), if maintained. You agree that the log(s) will be
located as indicated below. The coverage in any individual log must be for contiguous property except by arrangement with
the Inspector of Wires.
Attach suDDlementary sheets ifreauired fnr additional Ino Inratinn.c
-Log coverage, and location where it will be maintained
Responsible person
You may maintain the logs electronically upon agreement with the Inspector of Wires. If you intend to apply for such a proce-
dure, indicate below how the Inspector of Wires should access the log:
How many electricians and/or system technicians (as licensed by the Board of State Examiners of Electricians) do you employ
at your facility? Indicate the total number and also indicate the number of full-time equivalent staff that number includes:
Total electrical employment: Full-time equivalent electrical employment:
How many helpers' or apprentices do you employ to assist your licensed staff, under their direct supervision (see c. 141 §8)? In
general, this number must not exceed the ratio of one licensed individual to one unlicensed individual. Limited exceptions ap-
ply for veterans (see St. 1962, c. 582 §3 as amended by St. 1979, c. 156). Indicate the total number and also indicate the num-
ber of full-time equivalent staff that number includes:
Total electrical employment: Full-time equivalent electrical employment:
Not all electrical work for which notice to the Inspector of Wires is required must be performed by licensed personnel. How
many such persons, not required to be licensed, do you have in your employ? Indicate the total number and also indicate the
number of full-time equivalent staff that number includes:
Total electrical employment:
Full-time equivalent electrical employment:
*Institutions are defined f r these purposes as any person, firm, or corporation operating under c. 141 §8.
e �'� Ail (Please see reverse side for certifications and required signature.)
J
Institutional Permit Form, page 2
r
NOTE: Some institutions enter into contracts with contractors to perform ongoing electrical work at an institution, similar
to institutional employees. If, by the terms of such a contract, you direct the performance of such work, include the num-
bers of such employees in this application. If the contractor directs such performance, of if the contract period is for less
than one year, application must be made by the contractor on the. standard form for such work. Do not include such em-
nlovees in this application.
Please give your official title, such as "Director of the Physicdl Plant" or "Director of Facilities" or equivalent. -In addition,
provide a statement that substantiates your authority to hire electricians pursuant to c. 141 §8 for electrical work on the premis-
es of your institution, and to establish priorities for the performance thereof. This form is not to be construed as a grant of au-
thority to direct any licensee of the Board of State Examiners of Electricians to perform work in contravention of the rules of
said Board, or in contravention f the Massachusetts Electrical Code.
My title is:
My authority to act for the aforementioned institution is: IS o UOL�
I cert, under thapains and penalties of perjury, that the information on this application is true and complete.
N
(Dated)
(facsimile number;
0
The Commonwealth ofMassachusetts
Department of ludustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.massgavfdia
&Orkers' Compeassatio:a uarahed A.fdavit: Bm'lde #/Contractors
TO iiDMZvl? WXM TIM G A.Ti�kiO2
lfcatInformatio4Name (Budassngisxam
l
Address:
Phone #:
;i; e you an employer? 4ee(i 66,3 j0priale Bax:
an a
ar with etmiployees (full and/or part flame).+
I� I e?rrploy
2:[] I eta a sola proprietor or rano". 1p and have no employees w og for mein
.any oapaclty' [No workers' comp, it>simrnce segitiPai j
3.[] I am ahoMoownor doings!! workxmysot (Bo workers' comp. inwMcorc0red.] t
Iamah� and wlil be hiring contractcra to conduct all work on my property. 'VIM
4:
ensure them all colih.�o• either have tvorkcss' complws&trop insuran4aot are ser e
propriotors -.16 no ��lbyees.
511I81n.99enewcon00to>$�JA&Mhired the, sub-co�ractonlisted calfta#tachedOerh
Thwaub.contractor's have employ= andf Wo workers' eapmp. insrttanco:#
6.[]'Erireare acorporatipltpndr}aoftetshave oxen W-th*d&.*fW,mpti(MperMGI.c
IS2, $I(4), endwbbavano empldyees: (No workers' comp. itsgurance Mq&od.]
c Ari applicant that "_.1 . , t,st oleo 0 out the section below showing their workers' compensation po"cy iniormauoA '
t Homeowners who aubtnit tbie,vit Lmdicating they are doing all work and then hirer outside contractors must submit a stow affidavit indicating such
$Contractors that check tl 1rei5 must attached en additional sheet showing the name of the sub ntractboe= and statg whgther of lmotthose patitles have
empioyoes 7f the aulrao»haoto1s have employees; they must proyidt! their workers' comp. po oy
that is providing workers' compensation insurance for my employees^Below is thepolicy and)ob site
.1 am an employer
M
Type of project (required):
7. New'd6nstr6dilon
8. Remode&ik
9. ❑ Demolition
10 ❑ Building addition
ll.Zlecirscal repair's or additiops
P pin In ire 'airs or additions -
11[j RbUre*§
14.n Other
information.
Insurance Company Name —
. Expiration Dote: D/
policy # or Self -ins. Lic. n
lob Site Address:
15 i City/State/Zip: .4
Attach a copy of the �volrlcexs° ca pensation policy declaration page (showing the policy smvsnber and expiratiion dato .
by a Pirie up to $1,500.00
Failure to secuxe coverage as required under MGL o. 152, §25A is a criminal violation punishable
and/or one-year Imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine ofup to $250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance -
verification.
X do hereby certify
the
official use only. Do not write in this area, to be completed by city or town official:
City or Town:
PermitWcense #
is itue a_#a correcr.
Issuing A,uthoxity (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Phone #:
Contact Pelson
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