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N2�} r 5 Date .... �............ 6
N_ : � f
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........� y_ 4 ��. ....... .e..@. SC' . ...........................
t
has permission to perform ........ !. .►. f . 5 ..................
wiring in the building of .... V..4 ,..�.� Q ............................................
at ......✓ ......�?.�.i.Q.!�p�!. PS./.�u!�'`.... , North Andover, Mass.
Fee .....'�5. ... Lic. No.�' id S ..........
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• •ELECCAL INSPECTOR
�- i' A
07/28/98 08.53 k 15.00 SPAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
Department o Public Safety �menf f ty Occupancy &Fee Checked
UIVI.- BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work will be performed in accordance with the Massachusetts General Code. 5:7 CMR I2:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
City or Town of tic PUT �N 2e) V e, %2 To the Inspector of Wires:
The undersigned applies fora permit to perform the electrical work described below:
y 3�� S A2 HeaS POINd psi Ma Lot: '
Location (Street and �^� � p�
Owner or Tenant _9 0 e Z 1 VLt _A-4-4 _ _ Zone:
Oper's Address
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service Amps 0/ Volts
New Service Amps / Volts
Yes ❑ No ❑
(Check Appropriate Box)
Utilitv Authorization No.
Overhead ❑ Underground ❑ No. of lvleters
Overhead ❑ Underground ❑ No. of Meters
Number of Feeders and Ampacity
Locationand
n 2 I and Nature of Proposed Electrical Work , L � ^-v rAc �^ n CI_ et. Ac4aLC fL L� c�1c� ZN S f hl 01
i ) Jai t 1 t ti 0r ,a nr rl a ki i h� �
No. of Lighting OutletsI
No. of Hot tubs
No. of Transformers Total I<VA
No. of Lighting FixturesI
Swimming Pool Above grnd. ❑ In•grnd. ❑
I Generators KVA
No. of Receptacle Outlets
I No. of Oil Burners
I No. of Emerg. Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection -and
Initiating Devices
No. of Sounding Devices
No. of Self -Contained
Detection/Sounding Devices
No. of Ranges
No. of Air Cond. Total Tons
N.o. of Disposals
No. of Total Total
I Heat Pumps Tons nV
No. of Dishwashers
Space/Area Heating KAY
No. of Dryers I
Heating Devices KW
No. of Water Heaters KW
No. of Signs No. of Ballasts I
Local ❑ Muncipal Connection ❑ Other
No. of Hydro Massage Tubs (
No. of Motors Total HP I
Low Voltage Wiring
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy
including ompleted Operations Coverage or its substantial equivalent. YESy� NO C1I have submitted valid proof of same to this
office. YES X NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. .
INSURANCE BOND ❑ OTHER ❑ (Please Specify) 82 ,r, 90&q L e U; 1 4'
(Espt ation Datta
Estimated Value of Electrical Work S, Sa
Qy
Work to Start Inspection Date Requested: Rough Final
Signed under the penalties of perjury:
FIRM NAME O 5 S• LIC. NO. E 3 t S
Licensee S A M a Signature LIC NO. = -
Address d --Bus.' Tel. No. 'Soy • � 6 0 �S Z_ $'
Al
OWNER'S INSURANCE WAIVER. I am aware that the Licensee DOES NOT HAVE the insurance co 4rage omits substantial
equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Owner ❑ Agent ❑ (Plea'se t:heck one)
` Telephone No. PERMIT FEE S S
(Signature of Owner or Agent)
9S`i5 Jt� ec- tciZ
Date ... � .... : .�15
'.—10 9
.............. t ......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Thiscertifies that ........................ .................................... ................................
has permission to perform
....... ...
wiring in the building of .......... ) ....... .... �4—d ...........................................
at ..... --A&th Andover, Mass.
........... ....... i ..............
Fee...............
....... Lic. No/46.1
ELECTRICAL INS;;E
Check #
r+
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked&, 5—
[Rev. 1/071 Ilea,, hlanlrl
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 WINK OR TYPE ALL INFORMATION Date: - ' I�
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her int��;;7erform the electrical work described below.
Location (Street & Number) 3 �� 5������c�jr' orA�
Owner or Tenant
Owner's Address
saw
fk ^/,
Telephone No. 1W 7,73 " /2f
Is this permit in conjunction with a building permit? `�❑ No �� (Check Appropriate Box)
Purpose of Building , M Yes �►' Utility Authorization No. 0�//14110112
Existing Service t voAmps / ;I U Volts Overhead Und rd
g ❑ No. of Meters
New Service 2�O Amps l2� / ay�Volts Overhead � Und rd /
g ❑ No. of Meters
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work:
No. of Recessed Luminaires
No. of Luminaire Outlets
No. of Luminaires
No. of Receptacle Outlets
No. of Switches
No. of Ranges
No. of Waste Disposers
No. of Dishwashers
No. of Dryers
No. of Water KW
Heaters
o. Hydromassage Bathtubs
C n?"n ion of the following
No. of Ceil: Susp. (Paddle) Fans
No. of Hot Tubs
Swimming Pool Above ❑ In-
grnd grad ❑
No. of Oil Burn ---s
No. of Gas Burners
No. of Air Cond. Total'`
Ions
Heat PumP Nm
uber Tons KW
_._._ .... .
Totals: % .... ..._._.._..... ..................
Spacy&r6a-'Heating KW
Heating Appliances KW
Ko. of No. of
Signs Ballasts .
table may be waived by the
Generators /KVA
o.
ALARMS INo. of Zones
of Alerting Devices
❑iviunicipal
Cnnnnoiin. ❑ Other
No. of Devices or
:a Wiring:
No. of Devices or
No. of Motors Total Hp I Telecommunications
No of Devices or
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 Start: 6' _ 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 cove ge is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE V BOND ❑ OTHER ❑ (Specify:)
I certify, under the ains a d penalties of perjury, that the information on this application is true and complete. p
FIRM NAME: #e1a7y F �%sfi^L!/� Tyr -leo /n!, ��G �yC/ '/'J LIC. NO.: 1z���L�
Licensee: �/�;;r�1?!/�- Signature s'�� -
(If applicable, enter .1exem� t " in the{�cense number line.) r LIC. NO.: j'6
Address: Z?-R-tr rlI'e�`t �" U l%�Q�� Bus. Tel. No.: -,,PT/ �Zl F5e�
*Per M.G.L c. 147, s. 57-61, security work requires D c
artrnent of Public Safety "S" License: Alt. L l. 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: $ �`�
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 01rashington Street
Boston, MA 02111
' www mass gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
OR& Lnt Information
Nallle (Business/Organization/individual):
Address:
City/,State/Zip:
Phone
Type of Prelim (required):
6. ❑ Naw construction
7. Q Remodeling
8. Q Demolition
9. [] Building addition
1017Electrical repairs or additions
I I.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑.Other
omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1Contnectars that check this box must attached an addt"tio:raJ shrar s,'sowing the name of the soli -contractors and their workers `comp. policy in:ormatiuc
r I ant an employer that isprouiding:workers' compemadon insurance for nV 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 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 ps of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the fenaltieorm of a STOP WpRK 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.
! do hereby cern �under th ains and enalties of perjury that the information provided above is true and correct
Signature:�27
L7i/7/ --5"-1?
Official use only. Do not write in this area, to be completed by city or town official
A II City or Town:
Permit/License #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person
Phone #:
Are you an employer? Checktthe appropriate box:
l ❑ I
. employer with
4. ❑ I am a general contractor and I
ployees (full and/or part-time).*
have hired the sub -contractors
2. I am a.sole proprietor or partner.
listed on the attached sheet t
ship and have no employees
These sub -contractors have
working for me .in any capacity.
[No workers' comp, insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
reqmTed-]
3. Q I am a homeowner doing
officers have exercised their
all work
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, hisurance required_]
?H Any applicant that checks bo> # l must also flit out the section below showing their workers' compensation
Type of Prelim (required):
6. ❑ Naw construction
7. Q Remodeling
8. Q Demolition
9. [] Building addition
1017Electrical repairs or additions
I I.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑.Other
omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1Contnectars that check this box must attached an addt"tio:raJ shrar s,'sowing the name of the soli -contractors and their workers `comp. policy in:ormatiuc
r I ant an employer that isprouiding:workers' compemadon insurance for nV 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 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 ps of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the fenaltieorm of a STOP WpRK 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.
! do hereby cern �under th ains and enalties of perjury that the information provided above is true and correct
Signature:�27
L7i/7/ --5"-1?
Official use only. Do not write in this area, to be completed by city or town official
A II City or Town:
Permit/License #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector S. 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 cavy 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 numberlisted below. Self-insured companies should enter their
self-insurance license number on the'appropriate line. M
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 vvilI 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 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 # 617-727-7749
Revised 5-26-05
www.mass.govIdle