HomeMy WebLinkAboutMiscellaneous - 48 MONTEIRO WAY 4/30/2018 (2) 210/060.0-0145-000O.
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Date...�.2 ..:.�?�'....
NORTH
TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
.S
ACHU
This certifies that ................T �G...... ........................
has permission to perform
wiringin the building of....Y........M D III Tf
8 !?................. .......................
at . North Andover,Mass.
a Fee.l.S.." ---Lic.NW,9�.���..................
ELEMUCAL INSPECCOR
` Check
86 , �
5 Official Use Only
-` l ommonwea o/- addac elf
Permit No.
_. a.UePartment a��ire�erdic2d �
6'ccupancy artd Fee Checked
BOARD OF FIRE'PREVENTION REGULATIONS ' [Rev: 1-/071-., (leave blank)
APPLICATION. FOR PERMIT70 PERFORM-ELECTRICAL WORK
All work.to be'performed in accordance with the Massachusetts Electrics}Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORIILA;TION) Date:.,
City or Town of: ' � To the Inspector of Wires:
By this application the undersi ed wives notice of his or..her intention to perfprm he ejectrical work described below.
Location(Street&Number) i�'1°IOt�1 1 rte•. `:: Y9�
Owner or Tenant � �V �- Telephone No.
Owner's Address � �t
Is this permit in conjunction with a building permit?_ Yes No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / _Volts Overhead[IUndgrd.l No.of Meters
New Service Amps Volts Overhead❑ ' Undgrd❑ No.of Meters
Number of Feeders and Ampacity
Location pd Nature of Proposed Electrical Work:.
• ��,.11�c 'W l3 -
Com letion of the fWowin table may be waived by the Inspector of Wires.
No,of TOM
No.of I2ecessul Li:zziifmbres No.of Ccil.�-Sure,(Paddle)Fans r;nsfornzez s -XVA
)`lo. of f,uz;ziu;iz•e O)zflcis No.of ffot'f ib, G0.11crnfors
-- - - -- - —------- Above fn— l;o.0l.'1!;ii:i.cit caicy.t;)j hiin(3i---------
No,of'J�uzniu�ires crud,: �J gzud. ��
S�vizzzzniug J'pnl k�atle_y Units _ �--
No.of Receptacle Outlets No.of Oil Burners. FIRE ALARMS No.of Zones °
Burners
No.of Detection and
No.of Switches No.of Gas -Initiating Devices
No.of Ranges No.of Air Cond.- Toon No.of Alerting Devices
eat ump Num er ons I KW No-ofe - ontame
No..of.Waste Disposers Totals; Detection/Alerting Devices
Municl
A No.of Dishwashers Space/Area Heating KW Local[IConne hon ❑ Other
Heating Appliances KW ecurity Systems:*
No.of Dryers No.of Devices or Equivalent
l o.o Water KW" o.o o.o a Wiring:
Heaters signs Ballasts DatNa of Devices or E uivalent
No.Hydromassage Bathtubs No.of Motors Total HP e ecommuarcations wing:No.of Devices or Equivalent
OTHER:
Attach additional detail if desirez4 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 �Z BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains andpenalties of perjury,that the information on this application is true and complete.
FIRM NAME:ane t A 1Jl} t yo I UJ �1 LIC.NO.:�S�q-L
Signature �I,IC.NO.:
Licensee: --r - 7 -ter 173
(If applicable,enter "exempt"in license number/me.) Bus.Tel.No.
Address: 03 Alt.Tel.No.:
*Per M.G.L.c.147,s..5 -b 1,security work requires Department of Public Safety"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)C]owner ❑owner's anent.
Owner/Agent Telephone No. PEJUHT FEE:$
Signature
ps� The Commnszwealth of Massachusetts
Department o
" I '�' fwi P f Industrial
-el t k1 �dbi
J
Office of.Tnvestiaatio ns
� s b
600 Washington Street
Boston, M,4 02111
wwK-Pk&"S-,ov/dia
Workers' Compensation Insurance.A€Fiday..it: guilders/ContractorsTlectricians/Plumbers
An ficant Information
�7 �_.., R Please Print Legibly
NEune (Business/Organization/individual): b
Address:
y� r
City/State/Zip: 3 Phone#:
v7
EAre you an employer?Check the appropriate box:
I am a employer with 4. ❑ I am a aA Type of project(required):contractor and I
_in
(full and/or part-lime).* have hired the sub-contractors 6 New construction
2.�I am a sole proprietor or partner- listed on the attached sheet 4 ?• ❑ Remodeling
ship and have no employees These sub-contractors have
working for me in an ca aci workers' 8• ❑ DemoIition
y p comp. insurance.
[No workers' comp. insurance 5. ❑ We are a corporation and its 9. ❑ Building addition
3.❑ required] officers have-exercised their 10:0 Electrical repairs or additions
1 am a homeowner doing all work right of exemption per MGL I I. P ' Q
lumbi
myself. [No.workers comp. c. 152 ❑ nD repairs or additions
l(4); and we have no 12;❑ Roof repairs
insurance required.] t ert�ployees. [No.workers'
comp, insurance required.] 13•7 Other
*Any appli ant that checks box#1.must also fill out the section below showing tteeir workers'compensation policy inrortnation.
t.
riomcownets who submit.ihis aiidavti ittuicatitt�ti;ey att i uir:= t_:rc:r;
IC:
that check this box must attached an A ti
additional sheet showing ti?e Et'`n hire outside contractors must submii a new atnuav '
name of.i a sa cot tactors and their workers'comn.policy inr'otmation
t am an employer that is providing workers'compensation insu
in formation rance for my employees. Below is the poficJ,and job site
Insurance Company Name:
Policy#or Self-.ins. Lic.#:
Expiration Date:
Job Site Address:
Attach a copy of the workers' compensation policy declaration page(showing the Policy 1pnumbe
Failure to secure coverage as required under Section ',5A of MGL c. 152 can lead to the imposition of criminalr and penalti irationa oil 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 S250.00 a day against the violator. Be advised that a copy of this may be forwarded to the Office of
tement
Investigations of the DIA for insurance cov,age vesta
rification.
I do hereby certify under the p and panaldes orperjurY that the information f mation provided above is true and correct
Siortatur .
Date
Phone ao
Official use only. Do not write in this area, to be completed b3,city or town ofj-1ciaL
City or Town: PermitlLicense#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. CitylTowa
(.Other Clerk 4. Electrical Inspector S. Plumbing Inspector
Contact Person:
Phone#:
Information E .nd 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"..ever-y person in the service of another under any contract ofhire,
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 includizi.g 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 a r local licensing agency shall withhold the issuance or
renewal of a license or perinitto operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence mf 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 cont:acting 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 certincate(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'camperisation insurance. If an LLC or LLP does have -_
employees, a policy is required. Be advised that this affidavit maybe 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 quei r
stions regding the Iax�, or if you are required to obtain a workers'
compensation policy,please call the Department at the ni:xy_nber:listed below. Self ensu,cd 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 permitAicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permMicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under".lob Site Address"the applicant should write"all locations in (city or
town)." A copy of the affidavit that has been officially stasriped 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 Iicenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a Iice;ns� or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT requited to complete this affidavit.
The Office of Investigations would tike 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
DcTartrnent of Industrial Accidmts
Office of Invesfigations
600 'Washington Street
Boston; MA 62111
Tel # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26=05
Fax:9 617-727-7749
wuVx'.Mass.gov/dia