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Date-.�.
. . . .......... ........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
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This certifies that ...... �)et ?"YN
..................................................... ...............
.. .............
has permission to perform .............. 74.!? ... v,,f.. ....... ...............
whinpir the building of S�A�.J.L .. ..................................................................
at . .... ...... Lp� Noo� Ando�er,'Mass.
Fee..�� ... . ...... Lic. No" ........ . . ..........
ELEcTRiCAL INSPECTOR
Check
1 - 7
2 5 5
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Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 1 t
Occupancy and Fee Checked
[Rev. 1/071 leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code C), 527 MR 12.00
(PLEASE PRINT IN NK OR TYPE ALL INFORMATION) Date: % 2
City or Town of: NORTH ANDOVER To the Inspec or of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) J t --c S
Owner or Tenant 57-7.o J 6 5 A410
Owner's Address
Telephone No.
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.iqtn- 13
- Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters �--
i
Number of Feeders and Ampacity
1
Location and Nature of Proposed Electrical Work: �M P $ 6 ) t CAC:-�—
Completion ofthe following table may be waived by the Inspector 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- ❑o.
rnd. grnd.
of Emergency 4ighting
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. Tons Tot
No. of Alerting Devices
Heat Pump
Number
Tons
No. of Self -Contained
No. of Waste Dis osers
]?
Totals:
I.KW
Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
p g
Local ❑ Municipal El Other
Connection
No. of Dryers
Y
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:
No. of Devices or E uivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wtres.
Estimated Value of Electrical Work: ? p go (When required by municipal policy.)
Work to Start: 7 r ;- 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 c=BOND
m force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties ofperpury, that the information on this application is true and complete.
FIRM NAME .r�— LIC. NO.: /�So
Licensee: N- t_ L ,t rt (�� � i1A/. i nature LTC. NO.:
(f applicabl nter "exempt" in the license number line.) . Tel. No.: r2"
Address: S4— /,4 A til 3 Alt. Tel. No.:
*Per M.G.L 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) ❑ owner ❑ owner's agent.
Owner/AgentPERMIT FEE: $ U D
Signature Telephone No. ..
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed.
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an r
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass N
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass M
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass M
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com
0
The Commonwealth of Massachusetts
Department of IndustrialAccidents
X Congress Street, Suite 100
Boston, MA. 02114-2017
www mass.gov/dia
Compensation Insurance Affidavit: Builder/Contractors/Electricians/Pluinbers.
TO BE FILED WITH THE PERMTTING AUTHORi 'Y.
Naive (Business/(jrgariization/Individual):
Address: �- fl_ c X i 6 L_
City/State/Zip: Al's 0t _alone #:
Are you an employer? Check the appropriate box:
1.�1 am a employer with -employees (frill and/or part-time).*
2.❑ I am a sole proprietor or p - artnership and have no employees Working for me in
--.I
ca acity [No workers' comp. insurance required.]
P
3.F1 I am a homeowner doing all work myself [No workers' comp. insurance required.] t
<1 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
6. Q We are a corporation and its, officers have exercised their right of exemption per MGL c.
152 1(4) ,d We have no employdes. [No workers' comp. insurance required.]
Type of pro'ect (required):
7, ew`constni'ction
8. [] kemodeliAg
9. ❑ Demolition
10 [] Building addition
11.[] Electrical repairs or additions
1ZE] plmmbing repairs or additions
11E] Ro6f repairs
14.n Other
*Arty applicant that chdcks box #1 must �l' o chnu they are doing section below
ll work and then hire outside cmontracto�s must submit new affidavit indicating such.
Homeowners who submit this affidavi g
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
.....,,,i_,n 7ftihr. cnh-contractors have employees, they must provide their' workers' comp. policy number.
lam an employer that is providing workers' compensation insurance for my employees.
information.
Insurance Company Name:
P 'icy # or Self -ins. Lie. #:
Below is thepolicy andyob sate
Expiration Date:
o
�City/State/Zip c:rob Site Address:�—� Attach a copy o£the workers' compensation policy declaration pa a (showing the policy numberandpion da e).
lation
Failure to secure coverage as required under Mc. 152, §25A is a es in the form ofaSTOPal io ORDER and a fine of up to $250.00 a
and/or one-year imprisonment, as well as pen
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance
coverage verification.
Ido hereby cert nder tliepains andpenalties ofperjury that the information provided above is rue and. correct.
r(n t 6 lX T),Ff, 7,Le�( ti
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
permit/License 0.
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 Instrnctions
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 enierpri'se, 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 o£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 b6 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
applicalit-who has not produced -acceptable evidence of compliance with the insurance coverage xequired."
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 phone number(s) along with their certificates) 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-MA.SSAFE
Fax # 617•-727-7749
Revised 02-23-15 wwwmass.gov/dia