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Home My WebLink AboutMiscellaneous - 90 Kingston StreetWIRE LP I ---------- ""'o ................ Commonwealth o/ Ma69ac4udeth Apartment o f -7ire Servicee BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/07] leave blank 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: City or Town of: A j , A 0. j. zX To the Inspector of Wires: By this application the undersignbct gives notice of his or her intentio o perform the electrical work described below. Location (Street & Number) Owner or Tenant Yev i.c Owner's,Addrbss X, 4/ Is this permit in conjunction with a building permit? Purpose of Building Existing Service jJJ() Amps 2,2,&Volts New Service Amps / Volts Telephone No. Y ARA -- Yes ❑ No ❑ (Check Utility Authorization No. Overhead ❑ Undgrd[ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters ti Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: e �� N� e ! UC 9/�l /�/�l�n/2l. rrr � Comdetion of the fol lowina table may be waived by the I nscxrtor of Wires No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans V No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. grnd. o. o mergency Lighting 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 Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number I Tons ........... 1KW ..........'.." No. of Self -Contained Detection/Alerting Devices No. of Dishwashers 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 Heaters No. of No. o —Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Tel Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or asrequired by the Inspector of Wires. 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 I i censee provides proof of I i abi I i ty i nsurance i ncl udi ng " 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 Z. BOND ❑ OTHER ❑ (Specify:) I certify, under theand pen ties of perjury, that the information on this application istrue and complete. p ins FIRM NAME: ry LIC. NO.: Licensee: eli^V2 Signature LICV�m. NO.: (If applicable, enter `exempt" in ttfeIicensenumb line) / Bus. Tel. No.: Address: 3 i aK12 / ' A' 0i;4 // � - Alt. Tel. No.: k 2&3'01'? *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S' License. Lic. No. OWNER' S I NSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage nonnally required 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. 6 r { `�'�: S �v r The Commonwealth of Massachusetts . Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia yJy Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TBE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: 3 K Al &PAI _/7 GtY/State/Zip:/*e,//;-/ ///A,4— 0I�361 Phone#: 1-771 f7l)� Are you an employer? Check the appropriate box: 1. 1 ama employer with employees (full and/or part-time).* 2112. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. Q I am a homeowner doing all work myself, [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. ❑ 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): 7. ❑ New construction 8. E]Remodelilig 9. ❑ Demolition 10 [] Building addition 11.❑ Electrical repairs or additions 12.0 Plumbing repairs or additions 13.0 Roof repairs 14.0 Other *Any applicant that checks box 41 must also till 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 siibmit 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-conlracfors have employees, they must provide their workers' comp. policy number. I am an employer that is prdviding workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lie. Expiration Date: Job 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 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 day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certou)zder thepains and penalties ofperjury Ili at the information provided above rue and1orrect. 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 r j Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for theiremployees. 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-phoue 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. 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 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 a i Date .... .1 1`.'?�............ TOWN OF NORTH ANDOVER PERMIT FOR WIRING 9, C20 J This certifies that ....................... kc j� has permission to perform ......... e wiring in the building of.... ¢ v� ........................................................................................... at .........i..........1. ....... ........ ...........�....:.....4orth Andover, Mass. Fee...... ' ...... Lic. No.�o � .—........... ....... ELECTRICAL INSPECTOR Check # ,Z