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HomeMy WebLinkAboutSeptic System (3) Commonwealth ®f Massachusetts Official Use Only/ Permit No. /1 Department of FireServices Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank) APPLICATION NII ° TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: 7 `-' rC1 _ City or Town of. NORTH ANDOVER X-Me4Wector of Wires: By this application the undersigned gives notice of his or her intention t erfarm the ele ical work described below. Location(Street&Number) "Af - �"�;� """` Owner ar Tenant �" t. r. Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes �'" No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization tn No. ExistingService Amps Volts Overhead ❑ UndgidL "­ No.of Meters New Service Amps Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No.of Total No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hat Tubs Generators KVA Above In- o.o mergency Lig ting No.of Luminaires Swimming Pool rnd. F1rnd. E] Batter 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 Tot No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained F Totals: Detection/Alerting Devices_ Municipal No.of Dishwashers Space/Area Heating KW Local❑ Connection El Other No.of Dryers Heating Appliances Kyr Security Systems:Y No.of Devices or E uivalent No.of WaterKW 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 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 cove, e°is . force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) fy� p µp fp��Cy that A� s application is true and complete. I cern sander tlae airs atad ertalties o er sat ,that the ar�naataon on this FIRM NAME: . j LIC.NO.: 4711 ' I applicable,ente "ewer, n the - Signature LIC.NO.: Licensee: ;'l S � g (f Pp 6 line.) ,�°, �� licen e number � � � � us.Tel.No.: /� '� Address: Department of Public Safe Alt.Tel.No .a Per M.G.L e. 147 ss. 57-61,secure work requires De Safety"S"License: Lie.No. .ry F OWNERS 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. r ' ._. 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'ate�nsp ectzoxt xec�uixe�050.00)�C � p eetaxs' coxhMmfss � spectuxa' zgnatuxe��axni€ia7s) Yate The Commonwealth of Massachusetts Department ofIndustrial 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/fndividual)S Address: 6 r Ci /State/2i 1 City/State/Zi p•- .,%��� /'1 t..t,�.�°�d I I, r '", ..`7 - r't.C Phone#: ray"�"'�', :•f �- .� � / Are you an employer?Check the appropriate box: Type of project(required): 1.©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 2.❑ lam a sole proprietor or partner- listed on the attached sheet. Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9 E]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions . m selfo workers' comp, c. 152,§1(4),and we have no y [N p 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 aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContraetors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy anal joh site information. Insurance Company Name:. Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address , City/State/Zip: ,✓ ,r, ,� —� 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 tlo hereby certify under th f a/ids and penalties ofperjury that the information provided above is trice anti correct. - Si afore: Date: Phone#: -3 1 z��J 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 nstructions 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 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-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. De advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. AIso 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 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 ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA.02111 TeX, #61.7-727-4900 ext 406 or 1-877-MASSAFJ3 Revised 5-26-05 FaY,#617-727-7749 wWmMass,gov/dia