Loading...
HomeMy WebLinkAboutMiscellaneous - 41 SECOND STREET 4/30/2018 (3) ecr,-X " LE E, UL B] '� 'S F BUILDING FILE Date... .................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING sS,CHU e This certifies that ... ... ...................................................................................... has permission to perform ... ........................ .......................... CII.-I ............... wiring in the building of...... U-&-5 ...** A C rlo- at ............................................................. .........5A71.2-A-4.........N^Ih Andover,Mass. Fee. ..4.. Lic.No. ................. ELE Check# ?INAL�INSPECTO�R� 2 Commonwealth of Massachusetts Official Use Only { Department of Fire Services Permit No. 12-15115 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(ME ),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: A I? . ZO/� City or Town of: NORTH ANDOVER To the Jwspec&o WYires: By this application the undersigned gives once of his or her intention pt perff orm the a ctrical work described below. � a/� Location(Street&Number) l3 k.. � I ��� ��, `" 4 fC.P U t(T a Owner or Tenant 6e, ,e. Telephone No.9177-8'4-2-SW 3 Owner's Addresses Z8 EEarl�vo R ��✓✓�?ec m� Is this permit in conjunctionwitha building permit? Yes ZNo ❑ (Check Appropriate Box) Purpose of Building /c/Gf/r' / ,111,7b— Utility Authorization No. 2 yS%�/ 3 Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters 1 New Service ZO 0 Amps Volts Overhead Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location 2n/d Nature of Proposed Electrical Work: ULo //l. ��j�✓ l o 3 4JE' Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires g No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs 0 Generators KVA No.of Luminaires 8 Swimmin Pool Above ❑ In- ❑ o.o mergency Lighting ti g rnd. d. Ba!!ea Units No.of Receptacle Outlets No.of Oil Burners 0 FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges !. liiG►.5 No.of Air Cond. Z Toonsl No.of Alerting Devices In Heat Pump Number Tons No.of Self-Contained No.of Waste Disposers ` Totals: Detectio dAlerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Muni -Conn=, ❑ Other '\ No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water / KW No.of No.of Data Wiring: Heaters / G�G� Signs Ballasts No.of Devices or Equivalent J No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiringg• No.of Devices or E uivalent 5 OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of E!pctrical Work: (When required by municipal policy.) t Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURAN O GE: 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 cov ge 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 an'd�pnaloes ofperjury,that the information on this application is true and complete- FIRM NAME: .OiUC � /� LCLG� .�'d.!�7- LIC.NO.: ?c3 Licensee:�/�p ,� • je ;/ Signaturey'/t ,,pe- LIC.NO.: (If applicable,ent r' em tt rn e�icense number i ) us.Tel.NO. Address: �7 ' J It Tel.No.:21K F161-9 S�f *Per M.G.L c. 147,s.57-61,security work requires Department of Public Saf "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:$ � Fe - 1 -7 G� f _.the - - --- _ -be,�aptrrient o,fXntt`r�st�znlAccic�ents - • - Office ofXnvestigaflons 660 Washington.Street Roston,MA 02111 www-mass gov/dia w0rkml Compensation JfusTwance Affidadt:�uiXc ergs/Co z°aclox l +�cc rc cxansl�'X be ' .AwHeant Information PZeasePrin�Le�itbXv •Name(Busino,gorganizationll'n dvidual): .Address: � �mar-��i �� AV Phone : Are an employer?Check the appropriate box-. Type o roject(required):4. []I am a general contractor and I 1, I am.a employer with_,,�_, s. New cOnsiraction employees Galland/ox part time).* have likedthe sub-contractors 2.]] T am a sole proprietor or partner listed on the attached sheet.x '�• ]�Remodeling ship and`haveno.employees These sub-contraetorshave 8. E Demolition IF working forme in any capacity. workers'comp.insurance. 9• [l Building addition [NO worl-erS'eomp.zUsurauce 5. ❑We are a corporation and its 10.[]Electrical repairs or additions required.] officers have exercised.their 3.Elam.a homeownerd.039 all Work right of exemption perMCTL 11..[]Plumbingxepaim or additions myself.[Eo workers'comp. c.152,§1(4),and we,have no 12.[]Roofxepairs insurancuregwred.1? employees.[Nb workers' 13.[]Other comp.insurance required.] Mnyapplicantthatchecks box#1 mustalsofiUduftheseetionbeldwshovtingtheirworkerecompensation.policyi formation. Homeownerswho sabmitihisaffidavitindicat6gfhey9doing allworltandthenhireoutside contractors mustsu7imdtanew affidavitindicatiiigsuch. tContracfors that checkthis bo must attached an additional sheet sll I the name ofthe sub.-contractors and their workers'comp.policy infomlation. I am an einproyer that is.p�oviding wopXfers'compensation insur aitce�or�my er�toyees $atoty is the policy and j0 site in,formation. �?' . Insurance CompanyN'ame;. Policy#or Selz ins.L'ic.#: �✓� Expiration Date: /S Tob Site Address % v"� j fCity/State/Zip,- >��/'/,4/0, Attacb a copy of t�Ze workers'compensation-policy declaration page(showing.the policy number•and expiration crate). Failure to secure coverage as requixedundex Section 25A ofMGL o.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 civilpenalties in the form of a STOP WORD ORDER.and a fn.e ofup to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Tiavestigations of the ATA for insurance coverage verification. ado liereby ceptzfy uride,ilte pains amend,venatiies olpe.-Pry tfiatilie in,formation providecia7ove is true ancicoraect, Si afore• / . C�_ /fi' —' Date: X14. F/ �'✓'e�y Phone##• � �� �U a 7 / ©ffieiai arse oply. azo not write!a Mis area,to tie coigfeted by city or tow official; City or Town: Permit[License M lssuing.A.uthority(circle ane): 1.Board ofEtealth 2.Building lDepartment 3.City]Town Clerk 4.Electrical Inspector 5.Plumbing Inspector f.Other - - - - - -- _ Information ani.-Ins-t uctio . - --- _=_----_-- Massachusetts General Laws chapter 152 xecluires all employers to provide workers'comp emsation for their employees. _ Pursuaxit to this statute,an ern,Ployee is deemed as"...everyperson iii.the service of an under any contract o hire, express or implied,oral orwxitteu.,, An.enTloyWis deemed as"an individual,partnership,association,corporation or other legal entity,or any two oxmoxe ofthe foregoing engaged in a joint enfexp-rise,and including the legal xepxesentatives ofa`deceased employez,.or the receiver orfrtisfee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house havingnatmoxe than three apartments and wha resides therein,ox the ocoupant ofthe 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." MOL chapter 152,§25C(6)also states that"every state or Ideal licensing agency shall withhold the issuance or renewal of a license or Hermit 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'lel either the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic workunfil acceptable evidence of compliance with the insurance requirements of this chaptexhave beenpresented 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-confractor(s)name(s),addresses)and homenumber(s)along with their certificate(s)of Insurance. LimitedLiability Companies(LLC)or Limited LiabilityPartnerships(LLP)withno employees othexthatathe members orpartners,arenotrequiredto carryworkers'compamationlnsuxance. IfanLLC orLLP doeshave employees,apo7icyisxequ1:red. De advised thatthisaffidavit maybe,submitted tothe Depaztmentof Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should b e xetumed to the city or town that the applicatign for the permit or license is being requested,Aot the Department of Indusfrial Accidents. Shouldyou have any questions regarding the law or if you are required to obtain,a workers' comp ensatlonpolicy,please call theDepartment atthe number listedbelow. Self-insured companies should enter their self insurance license number on the appropriate line. City or Town Officials Pleasebe,sure thattheaf(idavitiscompleteaudprintedlegibly. The Department has provided a space at the bottom ofthe affidavitfoxyoutofill out in the event the Office oflnvestigationshas to contactyouregardingthe applicant. Please be-sure to SII inthe permit/11cense number wbichwill be used as a rezemuce number. 7n addition,an,applicant that must submit multiple permit/]femme applications in,any given year•,need only submit one i affidavit indicating current policy information(if necessary)and under"J•ob Site Address"the applicant should wxite"all locations in (city or towb):'A copy of the affidavit thathas been officially stamped ormarked by the city ortownmay beprovided fo the applicant asproof that avalid afCdavitisonfile oxfuturepexmifsoxlicenmes. Anew affidavitmustbefilleLdout each year.Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture s (i.e.a dog license or permit to burn leaves eta.)said person is NOT required to complete this affidavit. The Office of Invest gation4 would like to thank you in advance for your cooperation and should you have any questions, please do nothesitateto give us a call, 'the Department's address,telephone anal faxnumber: The Gm-mon-wealthofX1n�s�achv._.�e€t� _ Depaxtmeut Qfx.Rdu&ial ACCIdoat 6QQ WAlagtm Strut TOL 4 6IM-2 ,49QQ Qxt 406 Qx 1-87TM - Revised 5-26-05 www-may. -go-VIC is s ' ¢ 'COMMONWEALTH Cl, o • • • • • I BOA 1,C7 Uf- E>LE C.TR'I C1 .ANS S ISSUES THE FOLLOWING LICENSE AS -A ' REGJS:TERE:D MASTER E::LECTRICIAN ti MARK >•A N I EM I f a 45 SUMMER H`I LL PRA UT ria 01826-6500 15839 A 0731/i6 27181 !( g COMMONWEALTH OF MASSACHUSETTS ` • • - • • 1 .,B OARD OF f ELECTRICIANS I { ISSUES THE FOLLOWING LICENSE: A SL A `'REG JOURNEYMAN,: ELECTR.I C I-AN Ix \ �z ' . MAR:K. .A N I EM IUj 45 SUMMER H l LL' RD jy z DRAC'UT MA 01826 6500 �.<:. 33832 E 07/31/ib 27182 ! Date....�.Jelq................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ss�CHU This certifies that 'lee lm T .......................................................................................................................... k At has permission to perform ....V.,>-Ai-e................ ............................ wiring in the building of............. ..................................................................................... LA-4k-Z 4k '>eo at ........71yAndover Mass. ............................. Fee. .. . ............Lic.No.)�M.I.. ..N6 o c EL Check# Commonwealth of Massachusetts Official Use Only lug Department of Fire Services Permit No. 'Z��►� 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(ME ),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1�. T I 261/ City or Town of: NORTH ANDOVER To the spec r o Wires: Q� By this application the undersigned giv notice of his or her intention t perform the lectrical work described below. Location(Street&Number) 7S 7 S�G�l'IWc.)�+ km 4A Owner or Tenant 6e" E-T-g r Telephone No.` 79 9'S.3- S013 Owner's Addresses ,d����✓o° « � �� Is this permit in conjunction//with a building permit? Yes ZNo ❑ (Check Appropriate Box) Purpose of Building "+ J Utility Authorization No.Zt� 2 Existing Service Amps / Volts Overhead�❑ Undgrd❑ No.of Meters P �� Z I�l \\ New Service 2-0 0 Ams O / Volts Overhead Undgrd ❑ No.of Meters �_ Number of Feeders and Ampacity — 2 3 S �T/Ott 4 Location nd Nature of Proposed Electrical Work: � rva�t.el ��yl!/l1G Completion o the ollowin table maybe waivedby the Inspector of Wires. No.of Recessed Luminaires 8 No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Q Generators KVA i Above In- o.o Emergency Lighting No.of Luminaires `� Swimming Pool rnd. ❑ rnd. ❑ Battery Units i No.of Receptacle Outlets 6 No.of Oil Burners Q FIRE ALARMS No.of Zones No.of Switches 3� No.of Gas Burners �� No. Detection and Initiatin Devices No.of Ranges No.of Air Cond. Z Tons TotNo.of Alerting Devices No.of Waste Disposers tj Heat Pump Number Tons KW No.of Self-Contained __ _�. .._... __..___._._._._.'.__.._ _____ Detection/Alerting Devices No.of Dishwashers f Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of WaterKW�j No.of No.of Data Wiring: C Heaters 015 Si ns Ballasts No.of Devices or Equivalent J ' No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent S OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of El ctrical Work: (When required by municipal policy.) Work to Siart: ,�ZUU/ Inspections to be requested in accordance with MEC Rule'10,and upon completion. INSURANC O GE: 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 [BOND ❑ OTHER ❑ (Specify:) I certify,under the pains an�d p nalties of perjury,that the information on this application is true and complete. FIRM NAME: ,012/C 5LCC, 7LIC.NO.: Sc3 4 Licensee: �iQ ,� /�• /j//r��;'� Signature 4WrL• LIC.NO.: (If applicable,ent r"gxemallin the license number i ) / us.Tel.No.' -7f 'j 1 Address: 67 �U �-Jr" t.Tel.No.: /h Srj�f *Per M.G.L c. 147,s.57-61,security work requires Department of Public Saf "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 a ent. Owner/Agent Signature Telephone No. PERMIT FEE: S J Information-and Ins Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation fok their employees. Pursuant to this statute,an employee is defmod as"...everY person fi tho service of anothex under any contract of hire, express or•implied,oral orwritten." An erVloyei is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more ofthe Foregoing engaged is a joint enterprise,and including the legal xepxesentatives ofadeceased emplo ex,.or the receiver oxtnistee oan individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having notmore than three apartments and who resides therein,or the occupant ofthe dwelling house of another who employs poisons to do maintenance,construction ox repair work on such.dwelling house or onthe grounds orbuilding appurtenant thereto shallnot because of such employment be,deemed to bean employer." UQL chapter 152,§25C(6)also states that"every state or local Ileensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to constxuet 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`Weither the commonwealth nor any Of its political subdivisions shall enter into any contract for the performance ofpublic work until aeceptabla evidence of compliance with,the insurance requirements of Us chapter have b a on presented to the contracting authority." Applicants Please fill out the workers'compensailon affidavit completely,by checking the boxes that apply to your situation.and,if necessary,supply sub-contraotor(s)name(s),addresses)andphonenumber(s)along with Moir certificate(s)of a insurance. Limited Li ability Companies(LLC)orLimitedUabili Partnershi s ty p (LLP)withno employees otliexthailthe � members orpartuers,axe notrequired to carry workers'compensationimurancs. Han LL C orLLP does have em ployees,apolicyisxequired. Ba advisedthat-tbisafddavitmaybesubmittedtotheDepartnentof Industrial Accidents fox confirmation of insurance coverage. Also be suxe to sign and date the affidavit. ilia affidavit should be,retained to the city or town that the applicatign for the ermit or license is beingre d p est qu e ,nod the Dep'artnent of Industrial Accidents. Shouldyou have any questions regaxdmg the Iaw or if you are required to obtain,a Workers' comp ensation policy.,please call the Department at the number listed below. Self-insured companies shouldentertheir self insurance license number on the appropriate line. City or Town Officials Please be sure thatthe affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavitforyouto fM out in the event the Office of Xnvestigationshas to contact you regarding the applicant. Please be-sure to fill inthe por it/license number Whichwill be used as a reference number. In,addition,an applicant thatmust submitmultiple permit/license applications in any given year,need only submit one affidavit indicating current policy'information(ifnecessary)and under"rob Site.Address"the applicant shouldwxite"all locations in .(city or tOW10.D7.A:copy dthe affidavit that has bean off1dally stamped or marked by the city or town may bepxo-dded to the applicant aspxoofthatavalidaffidavit-isonErle�orfuturepermitsorlicenses. Anew afidavitmustbe.f edouteach year.Where a home owner or citizen is obtaining a license ox pemut not related to any business or commercial venture (i.e.a dog license orpermit to burn leaves etc)said p arson is NOT xe' ' d to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any ctuesgons, please do not hesitate to give us a call. The Department's address,telephone and faxen nbor.- TU 1)QTaX1MQRt Qfbdu*lal AAccXdWa Ofte offwamfrga.7aQn.a 6.0 Washington Sre Boo tan, 02111 Revised 5-26-05 Fax#617-727"7749 ' W�.xxta�s,gg.��clZa • ,.o r COMMONWEALTH OF MASSACHUSETTS BOARD OF ELEGTR.ICIANS ISSUES THE FOLLOWING LICENSE AS .A REGISTERED MASTER ELECTRICIAN ti MARK A NIEMI Z 45 SUMMER ht`I LL RD lu I)RAEUT. MA 01826 6500 15839 A 0731/16f < 27181 °COMMONWEALTH OF MASSACHUSETTS ;I m•]ku w rol Lai b. BOARD OF L.ECTR I C1 ANS !_ ISSUES THE FOLLOWING .LICENSE.. F As.:,..-.A REG JOURNEYMAN ELECTRICIAN w .Ix i1p. ,Q " MARK,.A NIEMI Z iy f I 45 SUMMERHILL RD:-, IW IU DRACUT MA 01826-6500 J 33832 > 07. 27182 I Date....... ....... ........................... OF r►ORT�y,� 3a; �oL TOWN OF NORTH ANDOVER O T �: . PERMIT FOR WIRING 'SSACHUS�t This certifies that . ....!` '. L 9 �'��' e , ...............�.... ......................r.:..............t.......................... has permission to perform ... . .........'...!....�F'e .�' .............................................................. wiring in the building of.......... .. ... a--�� . .............��5...........5.E�. .�!..U .,�C X .. ..... at ...................`'t C'" 'J........................................... orth Andover,Mas ............................. �� - ELECTRICAL INSPECTO 4 Check# Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services l Z� - BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee CheckedRev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MI ),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATIOA9 Date: s, zal�l City or Town of: NORTH ANDOVER To the Msped&o Wires: By this application the undersigned gives oti a of his or her intention tp perform tVIZ6 won described belo Location(Street&Number) sc�GQ�lr�l � � l �T.�� n Owner or Tenant e— E.rAiyG Telephone No.778 &'S'3S'z/3 `Y Owner's Address 2 �,� � t ��l ���i�hcc ,✓!1>p Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No.fz 2 y5—/ Existing Service Amps / Volts Overhead❑ Und rd g ❑ No.of Meters New Service 00© Amps /?0 /Zytl Volts Overhead Undgrd❑ No.of Meters Number of Feeders and Ampacity 3 — Z 3 S "'V]-,,00--v „ Location nd Nature of Proposed Electrical Work: 4Vj fu, �LGI/� ���; ��jj✓ lOf 3 fJJ� Completion of the following table may be waived by the Ins ector of Wires. No.of Recessed Luminaires g No,of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs 0 Generators KVA No.of Luminaires `8 Swimming Pool Above nd. ❑ In- ❑ mergency ig ng d. Batte Units � No.of Receptacle Outlets 6 No.of Oil Burners Q FIRE ALARMS No.of Zones No.of Detection and No.of Switches �� No.of Gas Burners -, Initiating Devices No.of Ranges Total No.of Alerting Devices g l�,Ct� No.of Air Cond. Z No.of Waste Disposers ` Heat Pump Number Tons KW No.o elf-Contained Totals: Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No,of Data Wirin Heaters �i�CS Si s Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs lNo.of Motors Total HP Telecommunications Wiringg: No.of Devices or E uivalent 5 OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of El trical Work: (When required by municipal policy.) 2 Work to Starr. c 1Ca/ In spections to be requested in accordance with MEC Rule 10,and upon completion. INSURAN O GE: 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 cov ge 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 and-p aloes ofperjury,that the information on this application is true and complete FIRM NAME: .O/�/� `L�'� GCL6 .�'�' ]'Y LIC.NO.: Licensee. y�,� , /U f � .���rl c. %E�'� Signature �- �+ �Xyiyy- LIC.NO.: (If applicable,ent r" c3Lij'hj?n / us.Tel.NO.- S/m�mtt Address: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Saf �License: L Lic.No y� 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:$ Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'comp ensation for their employees. Pursuant to this statute,an employee is defined as",.,every person in the service of another andel any contract oPhire, express or implied,oral orwr&eu." An employdis defined as"an individual,partnership,association,corporation,or otherlegal entity,or anytwo ormore of the foregoing engaged in a joint enterprise,and includingthe legal repxesentatives ofa-deceased employez,_or the xedeiver oxtnistee 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 o Ove dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or onthegrounds or building appurtenant thereto shall not because ofsuch employmentbe deemed to be an employer" MOL chapter 152,§25C(6)also states that"every state ox local licensing agency shall withhold the issuance ox 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 requ7 real:' Additionally;IVIGL chapter 152,§25CM states'Wbitherthe commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublie work until acceptable evidence of compliance with the insurance -requirements of this chapter have beenpresented to the contracting authority Applicants Please fill out the Workers'compensaizon of fidavit completely,by checking the boxes that apply to your situation,and,if � necessary,supply sub-contractor(s)name(s),addresses)andphonenumber(s)along with their certificate(s)of kmxauce. LimitedUabilityCompanies(LLC)oxLimitedLiabilityPartuerships(LLP)withno employees otlierthatrthe members or partners,arenotrequiredto caryworkers'campensationiasurance. 7f an LLC oxLLP doeshave em ployees,apolicyisxequired. B a advised thatthii affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to signs and date the affidavit. 'phe affidavit should be xetumed to the city or town that the application for the pemrit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the jaw or if you axe required to obtain a y�orkexs' 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 thatthe affidavit is complete andprinted legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of hZvestigations has to contact you regarding the applicant. Please be-sure to fill in the permit/license number whichwM be used as a reference number, in.addition,an,applicant thatmust submitmultiple permit/license applications in any givenyear,need only submit one affidavit indicating current policy information(ifnecessary)and under"Job Site Address"the applicant should wrill l to"aocations in (city or copy of the affidavit thathas been officially stamped ox marked by the city or town may be provided to the applicant as pz'oofthat a valid affidavit.—on,fdo ox future p ermits or licenses. A new affidavit must b e,filled out each year.Where a home owner or citizen is obtaining a license oxperanit not related to any business or commercial venture t (i.e.ad og license or permit to burn leaves eto.)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, )lease do nothesitate to give us a call. Department's address,telephone ai,d fax number: Tho CQmmoumalth of S as achv.:�Pff� - Depal"iMut d1lid-US-Wal Accidents Oeco ofTn 6.0Wasix�gq Boon, 4X TO,-9 61`�H��`��4900 ext 406 Qr-I-877�I�88=, - Revised 5-26-OS Fax 617-727-7749 ' 't�tvzxta�s,gov�ct�� COMMONWEALTH OF MASSACHUSETTS MI • . • •F' BOARD`O ELECTRICIANS . ISSUES THE FOLLOWING LICENSE AS REGI STEREO MASTER E:;LECTRICIAN MARK A NIEMI a 45 SUMMER _LL RD ' `� �%' gg .0 R' MA 01826-6500 ` 15839 A 2718 t COMMONWEALTH OF MASSACHUSETTS S. BOARD OF E'LEGTI I C I AN.S ISSUES THE FOLLOWING LICENSE s AS VREG J0URNEYMAN :ELECTRICIAN' ` MARK :A N I EMI ''!z 6.C 45 SUMMER HILL RD r ' AU 13RACUT MA 01826-65.... 00 33832 E 07'/3.11-/]l%6._..;.... 27182 I