HomeMy WebLinkAboutMiscellaneous - 75 MILK STREET 4/30/2018 (2)N
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THIS FILE
CONTAINS NO
DOCUMENTS
Date .....
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .� I'i/S TE �!v
..........................................................................................
has permission to perform &.G. ...(> �� do
....................................................................
wiring in the building of.
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........ ...............................................
f L North Andover, Mass.
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Fee .� �.tp:... ..... Lic. No... 1'
ELECTRICAL INSPECTOR
Check #
9240
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C.ONpHPn: ma .1ee/��I oac"
BOARD OF FIRE PREVENTION REGULATIONS
offici 1 Ube 041y
Permit No.
Occupancy and Fee Chocked _.._
[Rev. 1/071 leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 C'1VIR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:_ ?lel/r"
City or Town of: L/F TO the Irxspec:to • of Wire.v:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Sheet &Number) S / vi/;,/ sie'
—
Owner or Tenant Ayjk a'T NOP,e- i0 T/,r, 'L `. -- . Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes VI
Purpose of Building /7&v— � lr
Overhead ❑ Undgrd ❑
Overhead ❑ Undgrd
Existing Service Amps / Volts
New SMIU Amps / x Volts
Nu. of Meters
No. of Meters_
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: —>
Estimated Value of Electrical Work: ii0 69: _ (When required by municipal policy.)
Work to Start, -If— : a 2 Jv Inspections to be requested in accordance with MEC Mule 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 ET BOND ❑ OTHER ❑ (Specify:)
1 cera'fy, under the pains and penalties of perjury, that the inforrnadon on this applicat;oa is true and complete. �l
FIRMNAMES /��J , i LIC. NO.:
Licensee: �v Signature
LIC. NQ,: 10�7�
/If applicable, enter "exempt" in the !!cense number linea Bus. Tel, No.:�sf
Address. 7%2 v� e�h 7 ` Alt, 'Tel. No,: u � 37 0 "� v
Per M.C31, 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) [I owner, 2 owner's agent.
f V I Signstam ent Telephone No. PERM FEE: $ ���
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
ky www.mass.gov/dna
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrieiaus/Plumbers
Agolicaut Information
P1ri t Legibly
�rai�w•�a.ww.�r�n�rww�i� i�...r�w n
Name (Business/Organization/Individual):
Address: 1 �c.ct1� lP
City/State/Zip;
Are you an employer? Check the appropriate box:
1. [ 1 am a employer with?- 4. ❑ 1 am a general contractor and I
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
ship and have no ctnployeea These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
required.]
:3. ❑ 1 ant a homeowner doing all work
myself. [No workers' comp.
insurance required-] t
workers' comp. insurance.
5, Q We are a corporation and its
officers have exercised their
right of exemption per MGL
c, 152, §1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required)!
6, p'fiew construction
7, [] Remodeling
3. ❑ Demolition
4. Q Building addition
10,0 Electrical repairs or additions
11.[] Plumbing repairs or additions
12.❑ Roof repairs
13 J ] Other
"Any applicant that checks box #1 must alto fill out the section below showing their workcrF' compcmation policy inion vution.
t Homeowners who submit this affidavit indicating they are doing alt work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this bon ruri attached an aduitional sheet showing ttne nani. of the sub-contractorF and thcir workers' coop. policy i►i nnuariun.
,l am an employer that is providing workers' compensadon insurance fur my employees, Below is the policy and job silo
information.
Insurance Company Name: �% irJGifi" .^rn�C �/1l6 iL� r
Policy # or Self -ins. Lic• #:r_ (%
`OJEF_ cl 'uy `�' Expiration bate:
Job Site Address: -2 /,1/j/,/ STlcc.7- _ City/State/Zip:Z �n� U �1 z 44 rt
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 MGI, e. 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 forth 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,
1' do hereby certify
.a / — 2iAl
ofperjury that the information provided above is true and correct,
Official use only. Do not write in this area, to be completed by city or town official,
City or 'Gown: _ Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department a. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
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