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Home My WebLink AboutMiscellaneous - Suite 306�o 4 m 0 LAI : E • N Z e g elm C9O M z �Wy LUU� W ` } _ o� v Z O Z�g� d 0 d Y a �Y3 This certifies that ...Tl T .. /Aq / .So lt, % , v has permission to perform wiring in the building of .. �M. E,L� .1��1t..t�.r�.............. at ./.. Wl.�. 11..Sr......... North Andover, Mass. ELECTRICAL INS ECT C/ Check # ��_ 11201 N Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only It Permit No. !, l Z-.9 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),27 C, R 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: (( D ( Zo v -L City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his o her intention to perform the elect 'cal work described below. Location (Street & Number h e 'T "" 3 Q Owner or Tenant gy�AO� k t A-- C{. h Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: L...�__ No. of Recessed Luminaires -- - No. of Cell: Susp. (Paddle) Fans u ! inc 1ao eofvr v rr ireS. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above [IIn❑ rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection an Initiating Devices No. of Ranges No. of Air Cond. Total Tons Alerting No. of Devices g No. of Waste Disposers Heat Pump Totals: Number .' ' ...... Tons ' """"' KW """"' No. of Self -Contained Detection/Alert ng Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers No. of Water K`,�, Heaters Heating Appliances Kms/ No. of No. of Si ns Ballasts Security Systems: No. of Devices or Equivalent Data Wiring: �E7 No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP elecommumcationswiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: ( o Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVE GE: 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 cove age is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ✓❑BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjµry, that he itlformation on this application is true and complete. FIRM NAME: �T MA,1A U,,U LIC. NO.: Licensee: v Signature LIC. NO.: (If applicable, enter "exem t" in the license number lin .) {, Bus. Tel. No.: Address: fU3Lc.e� S„l 3 lt-iQ t . &4Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S I URA N WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by la y m i ature below, I hereby waive this requirement. I am the (check one ❑ owner ❑ owner's agent. Owner/Age t f Signature Telephone No. ((Jlt�q O� PERMIT FEE. $ �rY This certifies that ... Nom, . 4 ..�i�l ..................... has permission to perform ... 2-D..6-13 ........... wiring in the building of at .. Fee . .. Lic. NJ' Check # 2-1 O 11197 by, yr &A Q .� ...... , N rth Andover, Mass. hL+).... 05.... . ELECTRICAL INSPECTO Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use rOnly Permit No. l L T7 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 C), 527 C 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: l City or Town of: NORTH ANDOVER To the Inspector o Wires: By this application the undersignedgives otice o his or her intention to perform the electrical work described below. Location (Street &Number) 1 4, r i � D Owner or Tenant �'� '-"-'"`Telephone No. 1074 Owner's Address %�� Is this permit in conjunctionwitha building per/mit? Yes 54 Purpose of Building No ❑ (Check Appropriate Box) Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: lW�% L i-mmnletion of the following table may be waived bV the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: (Paddle) Fans IN of Total TransSusp. Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires 13 Swimming Pool Above ❑ In- ❑N rnd. rnd. -O -.-OT Emergency -O-.-O ig ting Battery Units No. of Receptacle Outlets 12/ No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. InDetection and of Initiatin Devices No. of Ranges No. of Air Cond. Tons Tot No. of Alerting Devices Heat Pump I Number ...... Tons ................ KW ....................... No. of Self -Contained No. of Waste Disposers Totals: I Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal ❑Other Connection No. of Dryers Y Heating Appliances Kit 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 Equivalent OTHER: Attach additional detail if desired, or as required 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 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:) I certify, under the pain=41;� enalties of pe jury, that tl information on this application is true and complete. FIRM NAME:. � LIC. NO.: Licensee:0111111X Signature LIC. NO.: (If applicable, enter "exe t" : the_license umb Bus. Tel. No.: Address: �� %y%!5 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department o Public Safety "S" License: Lie. 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/Agent PERMIT FEE: $ Signature Telephone No. . �'�sseu�--• -- �+'aiiefl�� ] �e-zuspsetiox� �•equixec�($�O.OU) � X � inspect. s' copnne�afs: - �i Rrr .b a xT'y' (.�nspeetoxs' ignatux' �xto �%tlals) - -- - • �laie . 3.'asse�i•-- [ �+'aiie[��) � ate-3�nspecizottxe�uixed ($0,00)-• [ � _ ' luspeetox.8' coinlneJxfs: - (ffisi eotorsl Sign.atu e -Co k1s) Pate 3, UNDVIR GRODND 7CNgJ'ECXXOIV. _ Passed - bas.pectoxs' coxnm.ents: (lnspecfoxs'Signature-aoinitials) Pate r ' &AE CA EN -0X N OXM CAR -1 � ; gsse(l-[ ) Waued--j e-inspectiottxequixer (50A0)� !speetbxs' comneits: (specfoxs'igtzaiuxe��oinztiais) bate ' 1�i7JCEC�xOd"I '-' OJIJCJ-vJ.�: ' ' sect -[)alter- [ )- ?enspecizoxtre0uixec�($50.00)� pactoxs' coznm.ents: 'w-.sp ectoxs' Signahwe -.ao Initials) date or, TAGN .AivJ 7 TO BY+ �+l� +�3� O'UT.A AGF+ FT Off' 19ITF,+ -W M .APXA TO BE INSPECTED 19 NOT The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 Uf I www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly 4wlva Name (Business/Organization/Individual): `2 Address:Zi City/State/Zip:/,r%�� At��/(.,��Phone #: 7 g�_,l Are you an employer? Check the appropriate box: Type of project (required): 1.0 I am a employer with �— 4. ❑ I am a general contractor and I ❑ ' 6. New construction employees (full and/or part-time).* have Hired the sub -contractors ❑Remodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # 19 ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.E1 Electrical repairs or additions required.] 'officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they Lire 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. I air an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. � / Insvance Company Name:. rL' �� Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address:l &//- ✓ Y • 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 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 hereby certify under the pains andpenalties ofperjury that the information provided`,, above is true and correct. Simature: % Date: Phone #: " f r✓ �� 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 #: 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 employeiis 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." M 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), 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 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 bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations 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 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, # 617-727-.4900 ext 406 or 1-877°,MASS.AFB Revised 5-26-05 Fax # 617-727-7741 www.mass,govldia