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HomeMy WebLinkAboutMiscellaneous - 554 FOSTER STREET 4/30/2018 (2) 554 FOSTER STREET 210/104.B-0005-0000.0 Date... !��.................. OF NORTh,� TOWN OF NORTH ANDOVER PERMIT FOR WIRING HU This certifies that ... . .............................................. ..................... . . ......................... has permission to perform . ..................... wiring in the building of ... ...................................................................... at ...... North Andover,Mass. ...... .........7................................................................ Fee ................Lic.No,;�)b .. 7j C hACTRIC Or Check 12049 Commonwealth of Massachusetts Off, - I Us 0Only r Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank �N 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 ININK OR TYPE ALL MFORMATIOA9 Date: /2— //- `2©/7 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) Owner or Tenant �iy17 s/ t ,(�� /� (L Telephone No. Owner's Address —� Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Q\ Purpose of Building Utility Authorization No. - Existing Service /,po Amps /20/,o g Volts OverheadZ9- Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity tk pn,. SAI-C-L Location and Nature of Proposed Electrical Work: r642 4. ai Ke ca-M S- Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ElIn- ❑ o.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets 5 No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches / No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges f No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump I Number Tons KW No.of Self-Contained ............................................. Totals: "' Detection/Alerting Devices No.of Dishwashers i Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: �,9�p (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. o 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 eergy,under the pains and penalties q gadury,that thein ormation on this application is true and complete. FIRM NAME: . �S _ _ LIC.NO.: ,�209 5k Licensee: © Signature LIC.NO.: (If applicable,enter "exempt".in the license ber liryg.) ,�A Bus.Tel.No.- Address: �� ,� cS! /�. NCO , o t gc{c. Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,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)❑owner ❑owner' gent. Owner/Agent PERMIT FEE: $ ' Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the ' permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166,§32,an l electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the 4 notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑ Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed❑' Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass R Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspecto s Signature: Date: ROUGH SPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comme s: � r Inspectors Sig ture: Date: FINAL INSPECTI Pass 0 Failed ❑' Re-Inspection Required($.) ❑ Inspectors Comments: 9 Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 u4p www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly (Business/Organization/Individual): Name Address: rK�(Q, S City/State/Zip: ,(/. � r/vc -le 75 hone#: en'r- Are you an employer?Check the appropriate box: Type of project(required): 1&*I am a employer with_ 2' 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. F1 Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9, ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance .re uiredemployees. [No workers' required.]i 13.[i Other comp.insurance required.] n *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Ti Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. r. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: 2 p/ 7 S(P—�S N - 4 r �v City/State/Zip: Job Site Address: � �' Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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. Ido hereby certify under Ili pains and penalties ofperjury that the information provided above is true and correct. �. Date: l 2 �� �� 3 SiMature: Phone#• �?b�A A 2l`�,�p 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 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: i 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 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' ' compensationolic lease call the r Y�P 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 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 burn 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 Defiartiment of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111. TeX,#617-727-4900 est 406 or 1-877MASSABB Revised 5-26-05 Fax#617-727-7749 www=ass.govfdia COMMONWE `t�F MAE SSaGFIUS ALTHTfS so�►R EL£CTRICLANS 1SUES THE FOLLOWING LICENSE AS ,A t :: RftS7ERED MASTER ELECTRICIAN: JOSEPH G ELKHOUft W n W 27 Fit- N �IOR7FI ANDD VER:>: M . 01845-1661+>`' zoo56. A 07/31,;/.lb .�.:..., 39271 .. • Q Date.. ...... 1308 cF 40Rr#j TOWN OF NORTH ANDOVER . PERMIT FOR PLUMBING .................................................. This certifies that.... .... ......... ....4 has permission to perform...... .................................................. -7// plumbing in the buildings of................... .......le, .......................................... . ...........r at.... / ........ &............................................. North Andover, Mass. FeeLic. NoA6.... .... .....HA............................................................. PLUMBING INSPECTOR Check# 2-3 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY MA DATE 1 i / ( PERMIT# `� � JOBSITE ADDRESS OWNER'S NAME��1 _ P OWNER ADDRESS S' -, TEL ZCpS:�FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL El RESIDENTIAL PRINT �,;� CLEARLY NEW: 0 RENOVATION: REPLACEMENT:O PLANS SUBMITTED: YES Q NOd FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM �- DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM _J __j ._.___( _._.__f .u__{ J DISHWASHER DRINKING FOUNTAIN f .-____f _---_ ______s _�.__f f _-_..__.-I _-__-� •-____J ___.__1 ._-__._ ___._. ._._..._1 __ _f .-•___.'• FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) P JL- KITCHEN SINK p _ -_! — J I__-j ___P -_-J LAVATORY f _f f _.J1 J J __.__..I J { ..___1 _: J: f. I 1 ROOF DRAIN SHOWER STALL -_,__-_f __ ___i _.._J SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING f f _f -...__._. j __ I _._-_J .J I I OTHER ._y..__.._J INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES VNO f IF YOU.CHECKED YES,PLEASE INDICATE THE PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND E--I OWNER'S INSURANCE WAIVER:I.am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 4� Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER —f AGENT I0 SIGNATURE OF OWNER OR AGENT S I hereby certify that all of the details and information I have submitted or entered regarding this application ar ccurate to the best of my kno ge 1 and that all plumbing work and installations performed under the permit issued for this application will be' complianc ith P ent provision o (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# SIGNATURE MPH" JP Q CORPORATION[]1#PARTNERSHIP 0# _ ? LLC COMPANY NAME ADDRESS CITY ,-,—� ------- -------...__..__r STATE � ZIP TEL Q`7 .7'7'- FAX _ CELL��EMAIL _ ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL IN/S;PECTION fSTES Yes NoSl 7 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# c PLAN REVIEW NOTES i i I i t 4 I - J+ s a�1 _ _ The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizatio0ndividual): Address: 20-0, &,X 0"a q, City/State/Zip:�`b reey 11?m.ti C11J4, _ Phone#: 92 g- Are ye employer?Check the appropriate box: Type of project(required): 1.Lt I am a employer with _ 4• ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.# [remodeling ship and'have no employees These sub-contractors have 8. E]Demolition working for me in any capacity. workers' comp.insurance. 9. []Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3. I am a homeowner doing all work g P right of exemption per MGL 11.[]Plumbing repairs or additions ❑ myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. 17 Policy#or Self-ins.Lic.#: �1YAXpirationDate: /1J6�• ��j� Job Site Address: �� <6S 4e, Sid• Pity/State/Zip.-Jo, ffa& Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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. Ido hereby cer ' un tlt pains and penalties of perjury�fihat �injform�atlon rovided above is true and correct Si ature e: � j Phone# �7 ��y 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 4.Electrical Inspector 5.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-contractor(s)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 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 burn 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 ofZndustrial Accidents Office of InVestigatlons 6.00 Washington Street Boston,MA,02111 Tel,#617-727-4900 oxt 406 or 1-877,MASSAFE Revised 5-26-05 Fax#a`617-727-7749 wWw-mass,gov/dia ;COMMONWEALTH OF MASSACHU''SETT • :.. -• • PLUIUI,BERS AND GASFITTERS, LICENSED AS A MASTER PLUMBER "ISSUES THE ABOVE LICENSE TO. i PAUL .._F FAUVEL 1 '170 :'SALEM RD W6ACUX MA 01826-2822 # 10`641. . 05/01/14 183301 AV •".. Date .l. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . `. . . . . . . .Ik . . . G,rJ . . . . . . . . . . . . . . . . . . . has permission to perform .11 ✓. � ? i.P . . . . . . . . . . . . . . . wiring in the building of . .. . (IZJA� . . . . . . . . . . . . . . . . . . . V at . . . . . . . . . .1))A . . � . h nd ver, Mass Fee.,.7. . Lic. No. . . . ELE R11 AL INSPECT Check# 2 11367 i F Commonwealth of Massachusetts Official Use Only 5ame Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] leaveblank 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: January 14,2013 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) 554 Foster Street Owner or Tenant Elizabeth Andrukaitis Telephone No. Owner's Address 554 Foster Street North Andover,MA. Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Exisitng Dwelling Utility Authorization No. Existing Service Amps 120/230 Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps 120/230 Volts Overhead❑ Undgrd No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �yLire septic ejector pump,float switches and control panel No. of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- o.o Emergency Lighting rnd. md. Battery Units No.of Receptacle Outlets No. of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No. of Waste Disposers Heat Pum Number .Tons KW........... No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local Municipal El [:1 Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No. of Motors E Total HP 1140 Telecommunications Wiring: No.of Devices or Equivalent OTHER: 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: 1/19/13 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 cert, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: bavid W Meehan LIC.NO.: 81296A Licensee: David W Meehan Signature LIC.NO.: 8126A (If applicable, enter "exempt"in the license number line.) Bus. Tel.No.: 978-587-7518 Address: 4 Mulberry Drive Peabody,MA.01960 Alt.Tel.No.: 978-535-4022 *Security System Contractor License required for this work;if applicable,enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally re- quired by law. By my signature below,I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's a ent. Owner/Agent PERMIT FEE: $ / Signature Telephone No. k The Commonwealth of Massachusetts i I Department of Industrial Accidents i Bt Office of Investigations i 'a r 600 Washington Street Boston, MA 02111 www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizadon/individual): David W Meehan Address: 4 Mulberry Drive City/State/Zip: Peabody, MA. 01960 Phone#: 978-535-4022 . Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. C] i am a general contractor and I b. New construction /employees(full and/or part-time).* have hired the sub-contractors 2.® I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. {]Demoliti.on working for me in any capacity. workers' comp.insurance. 9. Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10 Ell repairs or additions required,] officers have exercised their p 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t .employees.(No workers' comp. insurance required,] 13.❑Other *Any applicant that checks boz#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 must attached an additional sheet showing.the name of the subcontractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. insurance Company Name: Policy#or Self-ins.Lic.#:_ Expiration Date: .lob 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. Ido hereby ce 'y under the pains and pe ahies of perjury that the information provided above is true and correct. Signature: Date: I 8fo�-21 Phone#. � Jl" Official use only. Do not write in this area,to be completed by city or town official •City or Town: Permit/Ucense# issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityi town Clerk 4.Electrical inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: I �.-COMMONWEALTH OF IUTASSACHUSE3TS ELECTRICIANS REGISTER'EV':MASTER ELECTRICIAN ISSUES THE ABOVE LICENSE TO DA-1/1`D til °ME E HA N a.: 4 MULBE'.qRY DRIVE -PEA 0 D'Y MA 01960-4.6 a % 3 856483 f I'