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Home My WebLink AboutMiscellaneous - 6 Village Green 6 VILLAGE GREEN 210I046�003.A J f A Date... V �.................. C�r►ORT/y TOWN OF NORTH ANDOVER * PERMIT FOR WIRING ,;..:_ . ss�c►+us� Thiscertifies that ........... ................................ ........................................... .. .. .. has permission to perform ........ ��`t ' ' ./21i`r" .0 '1``t ............ ... ....... ................................................................................................... wiringin the building of...::...............:............................................................................. at .... G.:....Y.. './/'%'7C- `1) 2 ' �° -16 rth Andover ass. ........................................................................ Fee...`Pl.t)..... .........Lic.No.3.9/27............ -. . / 7 3 ELECTRICAL MPEC Check# ! 7 1, ' r 1 e Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT IN HK OR TYPE ALL.INFORMATION) Date: —K— �5: 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) �2 (/ �'I�a y .Q (9-�ef 0 d1l/l/.Q Owner or Tenant L/S!'f �m yr s Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Z vk -p Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: L U Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell.-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. Batter Units No.of Receptacle Outlets l No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No. of Detection and InitiatingDevices No.of Ranges l No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons I.K.W. .of Self-Contained Totals: """'""""""""""" "" """""' Detection/Alerting Devices No.of Dishwashers / Space/Area Heating KW Local❑ Munici�al F] Other Connec ion No.of Dryers Heating Appliances ger Security Systems:* N .of or 0 o e Equivalent No.of WaterKW 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: 'i Attach additional detail if desired,or as required by the Inspector of 97res. 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: 1NSURA-NCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties of perjury,that the information on this application is true and complete. FIRM NAME: . 'f'Yi r'e G 6✓g 10�r111Ay LIC.NO.: -59 7 Licensee: s'/f SignaturLIC.NO.: (y-pplicable,ent r "exempt"in the license number line.) Bus.Tel.No.-.. Address: 030W Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work req gyres 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's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. The Commonwealth of.Massa*seft _ Department oflndustriglAccMiks office of Investigations 600 Washington Street Boston,.MA 02111 -www.rnassgov/dia Workers'�CompensationTnsnxance.A fidadt:BuifdersfContractoxs7Elec�iclans f..,vubers Applicant�nformatxon Please Prim Leib Name(Business/Organizationftdividual): Address: Cxiy/Statelzip: Phone M .Are you an employer?Clieck the appropriate lox: Type of project(required): 4. ❑I am a general contractor,and I 1,[( I am a employer with 6. ❑New construction employees(fall and/or part time)* have likedthe sub-contractors a solo proprietor orpartner- 2.[l I am. r listed on the attached sheet. I. El Remodeling ship and'haveno.employees These sub-contractors have 8. E]Demolition working forme in any'capacity, workers'comp.insurance. 9, ElBuilding addition [No workers,comp.insurance 5. ❑We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exexcised.theix 3.0 1 am a homeowner doing all work right of exemption per MGL 11.[�Plwnbing repairs or additions myself.[No workers'comp. c.152,§1(4),and wehave no 12.p Rooi'repaks insuranceregaired.]� employees.[Noworkexs' 13.❑Other • comp.insurance required.] NAny applicantthat checks box#I rnustalso fill outtho seefion below showingtheirworkers'compensafionpolicy information. t'Homeowners who sabmittbis afCldavit indicatingthey ore dying allworleand then hire outside contractors must submit a new affidavit indicati$g such. TContractors that cheoktius box must affached,an gdditional sheet showingthe name of the sub-contractors and their workers'comp.policy information. I run an employer that is pYoviding workers'compensation insurance formy employees Below is z%2epolicy rantija i site information. Insurance Company Name:_ Policy#or 8elf*�ins.Lic.#: Expiration Date: Job Site Address' City%StateMp: Attach a copy of t ae workers'compensation-policy declaration page(sh.owing the policy number and expiration.date). Failure to secure oovexage as rRuiredunder Section 25A.ofMGL o.152 can lead to the imposition of criminal penalties of a x 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 tine of up to$250.00 a clay 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. X do 1;ereby cert f uiirjer ilzeiains andpenalties of penury that the information provided above is true and eorrect, Simature: Data: Phone#: Official use only. Do not write in t/ils area,to be com, Meted by city or town official. City or Town: permiMeense# Issuing.A.uthoriiy(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: f/ f The Commonwealth of Massachusetts Department of IndustrialAccidents a 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aaulicant Information Please Print Lezibly Name (Business/Organization/Individual): ,YAy-7t Address: r f t? C rGSS st City/State/Zip: een 5 6`307 Co Phone#: (`p O P—:31 V d 6l Are you an employer?Check the appropriate box: Type of project(required): LZ I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.F-1I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.[_1I am a homeowner and will be hiring contractors to conduct all work on my properly. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.F-]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t M 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 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: /_ Job Site Address: i/df R 6-r-e-Ph Da &-Q ?TW (O City/State/Zip: 1q17 4/0 V-0, Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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 da against the violator.A co of this statement may e y g copy y b forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do here�yer the ains and a lties o er'u that the in ormation rovided above is true and correct. P P fP J rJ' f PSi natu er Date: Phone#: </> r7lrr��733 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-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' 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia i r COMMONWEALTH OF MA . HUSETTS. i .. ISSUES:.,;;;THE F0LLOWNG''LICENSE ASA G J0URNEYI N ELUTTRIM AN �� C GENDREA..:U �+ r t Aa . . ti 21 PARKER 1 1 " o 0 4. 39197' E 07/31/1'6 60921 i ' I 4�b�IS fi ?YM