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Date....... : �...... �.
TOWN
c -
OF NORTH ANDOVER
PERMIT FOR WIRING
Thiscertifies that.............................................................................................
has permission to perform �'
....:.
/1�
wiring in the buildin of ...................... -..� ;�r
at.. ....`............. T
.�....................21ICAL
North
h�A'.nd'o-!sLv
e' r�„
Mass.
Fey:............... Lic. No. INSPECTOR .
Check # 4.1 / / ”
93:3
4c".\ Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 73L/3
Occupancy and Fee Checked 13s_`
[Rev. 11/991 t1Pav, hlankl
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: 4/14/10
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) 9 Mc Cabe Ct.
Owner or Tenant North Andover Housing Authority Telephone No.
Owner's. Address 1 Morkeski Meadows North Andover, Ma
Is this permit in conjunction with a building permit? Yes ®No ❑(Check Appropriate -Box)
Purpose of Building Public residential dwellings Utility Authorization No.
Existing Service Amps Volts Overhead ❑ Underground ❑ No. of Meters
New Service Amps Volts Overhead ❑ Underground ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work Examine and redevice/ refixture burned unit
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Total
Transformers KVA
No. of Lighting Outlets No. of Hot Tubs Generators KVA
No. of Lighting Fixtures 4 Swimming Pool Above ❑ In -1:1o. o Emergency Lighting 2
rnd. rnd. Battery Units
No. of Receptacle Outlets 15 No. of Oil Burners FIRE ALARMS No. of Zones
of
No. of Switches 8 No. of Gas Burners No. TnIn Detection and .c 3
itiatinu Device
No. of Ranges 1
No. of Air Cond. Total
Tons
No. of Alerting Devices 5
g
No. of Waste Disposers I
Heat Pump
Totals:
Number
I
Tons
I
I.Nw
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers Space/Area Heating KW 5000 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: 5
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
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:) Acadia 8/25/10
(Expiration Date)
Estimated Value of Electrical Work: $2000.00 (When required by municipal policy.)
Work to Start: 4/15/10 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: Sacca Electric, LLC LIC. NO.: 17258A
Licensee: Jason Sacca Signature `— LIC. NO.: 36232E
(If applicable, enter "exempt" in the license number line) Bus. Tel. No.: 603-635-3700
Address: 63 Jeremy Hill Road Pelham, NH 03076 Alt. Tel. No.: 603-231-8763
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.
ie ,
-C-\ Commonwealth of Massachusetts
NEW Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 73L/3
Occupancy and Fee Checked 3V1
[Rev. 11/99] (leave hlank)
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: 4/14/10
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) 9 Mc Cabe Ct.
Owner or Tenant North Andover Housing Authority Telephone No.
Owner's Address 1 Morkeski Meadows North Andover, Ma
Is this permit in conjunction with a building permit? Yes ®No ❑(Check Appropriate -Box)
Purpose of Building Public residential dwellings Utility Authorization No.
Existing Service Amps Volts Overhead ❑ Underground ❑ No. of Meters
New Service Amps Volts Overhead ❑ Underground ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work Examine and redevice/ refixture burned unit
Completion of the following table may be waived by the Inspector of Wires
No. of Recessed Fixtures
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures 4
Swimming Pool Above ❑ In- ❑
rnd. rnd.
o cy ig ing
Ba tte Units 2
No. of Receptacle Outlets 15
No. of Oil Burners
FIRE ALARMS
FNo. of Zones
No. of Switches 8
No. of Gas Burners
No. of Detection and 3
Initiating Devices
No. of Ranges 1
No. of Air Cond. Total
Tons
No. of Alerting Devices 5
No. of Waste Disposers 1
Heat Pump
Totals:
Number_Tons
.. . .
KW
.... . .
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW 5000
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances
g PP Kms'
Security Systems:
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring: 5
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
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:) Acadia 8/25/10
(Expiration Date)
Estimated Value of Electrical Work: $2000.00 (When required by municipal policy.)
Work to Start: 4/15/10 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the pains and penalties of perjury, that the information on this application is true and complete
FIRM NAME: Sacca Electric, LLC
LIC. NO.: 17258A
Licensee: Jason Sacca Signature LIC. NO.: 36232E
(If applicable, enter "exempt" in the license number line) Bus. Tel. No. 603-635-3700
Address: 63 Jeremy Hill Road Pelham, NH 03076 Alt. Tel. No.: 603-231-8763
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
Signature Telephone No. PERMIT FEE. -S
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/Organization/Individual): ,� 4 e ele f
Address: Co :� %Nf gA W AA k\.1 (L-
City/State/Zip: R-��e'ihn o�r Phone #:
Are you an employer? Check the appropriate box:
L ❑ I am a employer with
4. ❑ I am a.general contractor and I
employees (full and/or part-time).*
2. ❑ I
have hired the sub -contractors
am a sole proprietor or partner-
listed on the attached sheet. $
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself. [No workers' comp.
C. 152, § 1(4), and we have no
insurance required.] t
employees- [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ® Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
...�v i.., uui u:� sc::utm CelOW SnoRR.ng their kwon—'rs corII^a'^catinr....,i:..., information.
' 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 sub -contractors and their workers' comp. policy information.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address:_ _ ('A # ) City/State/Zip:_ JV p M%, >Aw1aD V C Q Mpw .
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.
I do herebycertify un er to in�penalties of perjury that the information provided above is true and correct
Dfficial 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):
I. 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 t6 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-contmctor(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
bee returned to the citr 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 bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would lice 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 of Industrial accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-72.7-49100 ext 406 or 1-8 77-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
wwu,.mass..gov/dia