HomeMy WebLinkAboutMiscellaneous - 75 RUSSETT LANE 4/30/2018Date ........ 'r
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
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This certifies that �'.:...../.........�.. 1:'................`c
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has permission to perform ....... ....... S� > -`� F a
..............................................................
wiring in the building of ..... ..:r. Vis:. �' �-
............... .... ..............................................
........ . .......... ..� ...................... . North Andover,Mas's.
Fee..,,?.� ............. Lic. No!% f;cf+.............../f..l.. � ............/........
ELECTRICAL INSPECTOR
Check #
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offs Official Use Only
Department of Fire Services Permit No. ,�/ 7
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked- h
v. 1/071
APPLICATION FOR PERMIT TO PERFORM EL (leave blank)
AD Work to be performed in accordance TRICAL WORK
with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE P.MTWINK OR TYPE ALL WonL4Y.70
City or Town of- NORTH ANDOVER Date: �� - iC' C
BY this application the undersigned gives notice of his or h,-, ' To the Inspector of Wires:
Location (Street & Number) f2 S tion to perform the electrical work described below.
Owner or Tenant
Owner's Address Telephone No. l,,
X7� 25gy
Is this permit in conjunction with a building permit?
Purpose of Building l.,J . z �Se \ Ye No ❑ (Check Appropriate Box)
2a @ �` Utility Authorization No.
Existing Service VC U Amps `Z= 'Volts
Overhead ❑ Undgrd �''� Nn. of Meters
New Sem `fps =_Volts
Number of Feeders and Ampacity Overhead 11 Undo d ❑ No, of Meters
Location and Nature of l tri
e
Proposed Electrical Work:
` ' l v S 3
of Recessed Luminaires
No. of Luminaire Outlets
No, of Luminaires
No- of Receptacle Outlets
No. of Switches
No. of Ranges
No- of Waste Disposers
--------------
No. of Dishwashers
No. of Dryers
a. of Water
Heaters
I
Hydromassage Bathtubs
OTHER:
L/
I
the
of Cet1--Susp. (Paddle) Fans
of Hot Tubs
mming Pool Abo e
of On Berne .
a. of Gas Burners
o. of Air Cond.
Space/Area $eating iC`9l'
Heating Appliances
KW
n. of o. of
Sims Ballasts
win table may be waived b the Inspect,
Na. of Total
Transformers KVA
Generators KVA
lvo. of lime. ency ung
'IRE ALARMS No. of Zones
o -of eteciion and
Initiating Devices
I- of Alerting Devices
o, of elf: ontained
etection/Al ri' g Devices
)cal[] Mamcipal
Connection ❑ Other
'Cluny Systems-..*
No. of Devices or E uivalent
tta W;
o. of Motors Total �Teli�co.j�
Estimated Value of Electrical Work: �O� mach additional detail if desired, oras required
( by the Inspector of Wires,
Work to Start: , (R'hen required by municipal policy.)
� e,� Inspections to be requested in accordance with MEC Rale 10, and upon •co lotion
INSURANCE COVERAGE: Unless waived by the owner no mP
the licensee provides proof of liability insurance including permit for the performance of electrical work may issue unless
undersigned certifies that such coverage is in force, and completed operation" coverage or its substantial equivalent The
CHECK ONE: 1NS has exhibited proof of same to the permit issuing office..
UR.ANCL�®-BOND ❑ OTHER
I ceriify, under the pains and penalties o ❑ (Specify )
FIRM NAME: fP�7ury, that the information on this application is true and complete.
<-ez c ' e^ l ec- i- t -ccs
Licensee: LIC. NO.:
(If applicable, enter eenpt to to license number line.) Signature .V_•
��JJ LIC. NO
Address: a �+�
nn Bus. TeL No.:
*Per M.G.L c. 147, s.'57-61, security work reIJP � � � � �`-� U�
OWNER'S INSURANCE W quires Departrnern of Public Safety "S- License: Alt Tec No.:.
RIVER: I am aware that the Licensee does not have the liabilityLic. No.
Owner/Agent w. By my signature below, I hereby waive this requirement I am the (check one) ❑ owner °overage normally
Signatare ❑ owner's agent
Telephone No. PERMIT FEE: $�— �
CommaaWarra of Marsachrrs .
efts
Departnnert OffnduS&W Accidents
'tee a
� f Investigations .
tic600 Rzashirt� ion Street'
Bovtoft, M,4 02111
r�
Workers' Compensation Ins prance WWW.m4ssgov1dia
A
cant Information Anidavit: BuilderslContractorsmec-tricians/Pfambera
Please Print Leeibh
dame (Rosiness COrgani�on/Individual); --/�
C)L
Address:
Clay/5tete/Zig: (� '4' (' V"N •A
Are yon an employer? Check the approprmte•box:
'�-I°arn a em i
Phone
P oyer wtih _
=Ploy= (foil and/or -time). *
4. Q I mn a general contractor and I
pari .
2• ❑ .I am.asole proprietor. or
have: hired the std-eontracrtors
partner-
ship and have no em 1 ees
oY
Iisted � the attached sheet f
working forme in an Y capacity.workers,
�� suh-contractots have
o work='
> 'comp. insurance
'
comp, insurance.
5. ❑ We are a corporation
e
.required.] �
3• Q I am a homeowner doing
and its ...
officers have exercised their
ail work
myself. o•w ' comp.
ri ' t of exemption per MGL
'
insurance requutd;] t _
• )S2, § 1(�4 and we have no
•emPloYees, [No workers'
Type -of project ("Direct) —
.6. Q New construction
7. ❑ Remodeling
S. Q Demolition`
9• ❑ Bwlding addition
1 O.Q OOctrical repairsradditi..
11.(] Plumbing repairs or additions
12.0 Roof repairs
comp. insurance required.]: I I3.Q.Other
�A"3' aPPlicxnt that checks box# l mora also fit! out the section below chis , • 1
t EMM=tO nerd who sabmrt this drWzvrt u�di=trngthey ass; dem ep wo wretg !herr tvorkars oompeosation of
;�noactors that ahwk this' box B rk and then hbe•omeide eontractonr P '� mforntahon
mustWMahed an addifioasl shotshowing the Dame of the sub�coneruutumn-t 8�n a Dew affi"vit indi
cstinR each.
..err. an ernptof er that•is • ro _ , -- csw`r worxers cootP• poEicy inb=don.
utfomnaao matrtg:warkerts eontpewardojz irrswUneeforniy.emp(oyLM B
Insurancelow is.the o
' e � P �y ®ird job srer
Company Name:L/`c
Policy # or Self -ins. Lic. #: ( -1 TI ( Ca
Job Sitz Address: Expiration Daft.
Attach a copy ofthe .workers' compensation Crty/S�'
policy decl$r$baD l (showing the policy Dumber and expiration date}
Pallors to secure coverage as required under Section 25A of
fine up to $1,50(,00 and/or one- MGL c. 152 can lead to the imposition of crsminal
Of up to 5250.00 a da Year imprisonment, as well 8s civil penalties in the form of a Peres of a
Y against the vioiat0r. Be advised that a c STOP WORK �RDERand a fine
Investigations of this DIA for insurance cove v oPY of this statement may be forwarded to the
Office of
rage erification.
I do hereby certify under the pains and penalties• o
lPed"r]' tfzat Me4f, P vided above a
u{f rmatioa m ' wee ani/ correct
Si�nsture� . Com/` ._--• .. -
'hone #: Dater v
Ojj"zcial use only. do not write ie this arm¢, m.;bt contpie�! Y �, or town VffaioL
City or Town:
Issuing Permit/LicenseAuthority (circle #
one):
I. Board ofHeaEt6 Z Building Department 3. City/Town Ci
6.Otlper erlt 4 Eh:etrical Inspector S. Plumbing fur
Pecfar
Contact Person:
Phone #
4
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 impiied, oral or written"
An ernployer is defined as "an individual, partnership, assodiation, corporation or other legal entity, or any two ormore
ofthelb=going engaged in a joint enterprise, and includirig the legal representafivw of a deceased employer, brthe
receiver or trustee -of an individual, partnership, association or.other legal entity, employing empioyem 'Howevcthe
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 re pair wcirk as such dwelling house
or on the grounds or building appurtenarn 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 commonwealtif nar any of its -political subdivisions shall
enter into any eantract for the performance of public worse Until -acceptable evidence of compliance with the insurance
requirtmants'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), addresses) grid phone mvnber(s) along with their c ertificate(s)' of
insusarim Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no. employees otherthm the
members or partners, are not inquired to cavy workers' ccarnpensaiion insurance. if an LLC. or LLP does have
empioyees, a .policy is required. Be advised.tim this afi davit.may be submitted to the Depmriment 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 pwmit or license is being requested, not'the Department of
Industrial Accidents. Should you have any questions regarding the law or if you .= required to obtain a workers'.
compensation policy,:please-call the Department at the -nurnber. listed below. Self-insured companies should enter their
seif-iniscuancelicansc number on tiro appropriate lint.
City or.Town Officials
Please be sure that the affidavit is complete and printed ieglbiy. 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.
se
Pleabe sire to fill in fire permit/license number which wiII be used as a reference number.. in addition, an applicant
that. must submit multiple.permit/iicease applications in any given year, need only submit one affidavit indicating•eurrent
policy information (if necessary) and under "Job Site Adcb-e w- the applicant should write "all locations in (city or
town)." A copy ofikre affidavit gut has bean officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid -affidavit is on Hie for filtin-c permits or licenses. Anew 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 bum leaves eft.) said person. is NOT required to complete this affidavit
7brOfficz of Invmdeatipns 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 Depamnent's address, telephone and fax number.
The Commonwealth of Massachuse=
DePartmznt of Industrial Accidents
Office Qf Imeafigsiions
600 Washington Street
Boston-, h'IA 02111
TeL 9 617-7274900 ext 406 or 14774 ASSAFE
Revised 5-26-05
Fax T 617-727-774€9
4Z/VSTVi'.II22SS. goo/dia