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HomeMy WebLinkAboutWiring Permit (s) - Correspondence - 1160 GREAT POND ROAD 8/20/2014 p Date .•....... ......... F k y ..... . 5 o�NORTMor .. �\ =T /N OF NORTH ANDOVER o a r PERMIT FOR WIRING r r N This certifies that ` V I� ..... 1 has permission to perform ......... .a ` r •` . e : .................... ` wiring in the building of '. �� North Andover,Mass. r , at Lic.No.b......... �. Er ica t ItasrEcrox.i' 2 Check# Commonwealth of Massachusetts Official use Only Permit No. 21,A,� Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Rev. 11/991 Wveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMK 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 6191dot y T'- . City or Town of: Mt)L dt /�A&)), &c_- 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) 116y 6te,4-A P,1c( t2oA-el Owner or Tenant bb le-y erh�� / Telephone No. }7 )Z� , Owner's Address 1166 czela ! -�n!, 410tvl Is this permit in conjunction with a building permit? Yes ❑ No � (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps �Za / OO Volts Overhead � Undgrd ❑ No.of Meters �e v"Se .ce Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: T ov. v1Le �, ,✓� CY � pn o the olloKin table may be waived b the Inspector o Wires. No.of Total rNot.ofRecess Fixtures No.of Ceil-Susp.(Paddle) Fans Transformers KVA No,of Lighting Outlets No.of Hot Tubs Generators 'A o. o mergency Lighting No. of Lighting Fixtures Swimming Pool rnd. ❑ rtid. ❑ Batte Units No.of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones o.of Detection an No.of Switches No. of Gas Burners Initiating Devices No.of Ranges No. of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heaf Pump Number Tons KW No.of Self-Contained erti P TotaLs: Detection/Al Devices Municipal Other No. of Dishwashers Space/Area Heating KW Local ❑ Connection ❑ No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent, No. of Water R'W o.o o.of— Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs [No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail ifdesired,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 cove age is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [ BOND ❑ OTHER ❑ (Specify.) �p � 7 ®Q� (Expiration Date) Estimated Value of Electrical Work: " (When required by municipal policy.) Work to Start: tq Inspections to be requested in accordance with MEC Rule 10,and upon completion. Icertify, under a ins andpenaldes ofperiury,that the information on this application is true and complete. FIRM NAME: j. LIC.NO:: Licensee: 6S T2 (� ,� Signatur LIC.NO.:j �� (If applicable enter"ex t"in the&ense nwnber line) Bus.Tel.No.�S�'l-y'`Ef-PW Z Alt.Tel.No Address: p �3 D /� ob D� _ .:6t ��`� 4ti ld OWNER'S INSURANCE W VER IYaniaware that the Licensee does not have the liability insurance coverage normally required by law. Bymny signature below,I hereby waive this require ent. I am the(check one El owner ❑ owner's a ent. Owner/AQent TII `-7 ��'r° PF.RAffT D. INSURER'S AFFIDAVIT AS TO WORKER'S COMPENSATION INSURANCE I Alliant Insurance, 131 Oliver St., Boston, MA 02110 [Name,Address] am: an authorized representative of Insurance Company [Company Name] (a producer`in the voluntary market)t an authorized agent of Travelers Insurance Company(an agent in the voluntary [Company Name] market,authorized to sign on behalf of a producer)t an authorized signatory of the ,the Prime Contractor(an insured [Company Name] of a producer in the involuntary market pool)$ an authorized signatory of ,the Sub-Contractor(an insured of [Company Name] a producer in the involuntary market pool, group, or otherwise insured)l and do hereby aver that effective July 15, 2013 [Date], Power Line Contractors,Inc.,the Prime or Sub-Contractor,is insured for Workers' Compensation insurance with Travelers Casualty and Surety Insurance Company under Policy No[s]. DTAUB7820N07413 ,pursuant to the attached Certificate of Insurance,and in accordance with Massachusetts General Laws, Chapter 152 and Subsection 7.05A of the Standard Specifications for Highways and Bridges of the Highway Division of the Massachusetts Department of Transportation. Ig re 4Ass nt Account Representative Title I COMMONWEALTH OF MASSACHUSETTS On this 19th day of July , 20�3before me, the undersigned notary public,personally appeared Stephen Turner [document signer],proved to me through satisfactory evidence of identification,which was/were , to be the person who signed the preceding or attached document in my presence, and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of their knowledge and belief. I t ,Notary t ( [Printed Name] E ICOL.E POY Notary Public ALTH OF MA55ACHUSETTS Ulf ommission Expires July 20,2018 A producer is an insurance company that provides insurance policies directly,not an insurance agent. t For Prime or Sub-Contractor companies insured through the voluntary market,this Affidavit must be completed by the insurer or an authorized agent of the insurer. t If the Prime or Sub-Contractor is insured through the involuntary insurance market,a pool,such as the Worker's Compensation Inspection and Rating Bureau,or is otherwise insured they may provide a Certificate of Insurance and this Affidavit which may be signed by an authorized signatory(company officer)of the Prime or the Sub-Contractor. --- - - - — 15 AIR" CERTIFICATE OF LIABILITY INSURANCE 7/10/2(h DnYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT NAME: Aaron Ka afar Alliant Insurance Services, Inc. PHONE 617-535-7200 (FAX,Not:617-535-7205 131 Oliver St. 4th Floor � °t°.�t)' Boston MA 02110 E-MA'L .akayafas@alliant.com __INSURERS AFFORDING COVERAGE NAIC# INSURERA:Travelers Casualty and Suret Coma 19038 INSURED POWELIN-01 INSURERB:Charter Oak Fire Insurance Company 25615 Power Line Contractors, Inc. INSURERC:Travelers Property Casualty Co.of 25674 PO Box 2059 Woburn MA 01888 'NsuRERO:Travelers Indemnity Company 25658 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:758135168 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DD S POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MMIDD/YYYY MMIDDIYYYY D X COMMERCIAL GENERAL LIABILITY DT-CO-7815N304-IND-14 /15/2014 7/15/2015 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES Ea occurrence $300,000 MED EXP(Any one person) S5,000 PERSONAL&ADV INJURY S1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S2,000,000 POLICY a JECT PRO-- E LOC PRODUCTS-COMP/OPAGG $2,000,000 OTHER: $ COMBINED S B AUTOMOBILE LIABILITY DT-BA-7876N506-COF-14 /15/2014 /15/2015 Ea accident I M $1,000,000 ANY AUTO BODILY INJURY(Per person) S AUT OWNED SCHEDULED BODILY INJURY(Per accident) $ UTOS HIRED AUTOS X NON-OWNED PROPERTY DAMAGE S XIAUTOS Per accident _ S C X UMBRELLA LIAB X OCCUR DTSM-CUP-7876N518-TIL-14 /15/2014 /15/2015 EACH OCCURRENCE $10,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $10,000,000 DIED X I RETENTIONS10,000 S A WORKERS COMPENSATION DT-UB-782ON074-14 /15/2014 /15/2015 X PER X OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S1,000,000 OFFICER/MEMBER EXCLUDED? ❑N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEd$1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT 1$1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Power Line Contractors, Inc. ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 2059 Woburn MA 01888 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Fold,Then Detach Along All Perforations COMMONWEALTH OF MA.SSA T:CHUS1 &;` BOAAD 1 SSUES TH.E FOLLOWI NG L I CENSE AS A REGISTERED :MASTER..E';L E CTR I C I AN : a 'z ROWER LINE CONTRACTORS INC `'JAMES R D.AGLE z PO Box 2059 WOSURN MA 01888-0059 17087. A 07/31/i6 70005 i Date.............. ate............... .. .. I kORrh. TOWN OF NORTH ANDOVER p PERMIT FOR WIRING 88�CHUa� i This certifies thaVt '< d t................................... ...... ........:.. .............................:.....o. ..:. . ... .: P � A has permission to perform .. .... :: . n ° � wiring in the building of... d�. .z:., .. .:....�, . ...`.. R................' .. ..... ray at .... � ," .... ........... orth Andover,Mass. ........ I Fee.. �. ........Lic. No... .. � rT...... ........... EL CAL INSPEC jo Check# a " Commonwea&o f/I"ladea4watb Official Use Only, c� Permit No. 2epartnwnt o 3ire Serviced BOARD OF FIRE PREVENTION REGULATIONS 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(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: IJ t 3 j- City or Town of: Q n r .V''t+tico vim/ To the Inspector of Wires: �= By this application the undersigned gives notice of his or her intention to perform the electrical work described below, f' Location(Street&Number) C61'4 (Z.., Ck Gc",v,.o Owner or Tenant �.r Telephone No. Owner's Address �bo 6,-,V Ou, )t b Is this permit in conjunction with a building permit? Yes No ® (Check Appropriate Box) Purpose of Building A Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters New Service X 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 lvaived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No. of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In El .o Emergency Lighting rnd. rnd. 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 Initiatin Devices No.of Ranges No.of Air Cond. Total Tons No. of Alerting Devices Heat Pump Number Tons KW No. of Self-Contained > No.of Waste Disposers ............... ............. ....................... Totals: Detection/Alerting Devices al No.of Dishwashers I Space/Area Heating KW Local❑ ConnecMuniction El Other No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: p� Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No. of Motors Total HP Telecommunications NofDevices r Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of 9,7res. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: �2-)--XcA 3 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. CHECI{ONE: INSURANCE E] BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of petjuty,that the information on this application is true and complete. FIRM NAME: Amore Electric, Inc. 1 LIC.NO.: Licensee: Anthony Amore Signature , ,�;' ,�:,;� _�, ;�G ------I-,IC.NO.: Al5375 I a licabl n er "e n ua t e 1'cense n rnb�r!i .1 Bus.Tel.No.:978-372-5877 (f r f�vco c���Jr I�averhi��, MA S'935 - Address: Alt.Tel.No.: �- *Per M.G.L.c. 147,s. 57-61,security work requires Department of 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 l`� Signature Telephone No. PERMIT FEE: $ plow L- '.COMMONWEALTH OF MAS-SACHUSETT BOAt�}� EL t:T IC(ANS ISSUES THE FOLLOWING LICENSE AS A;: REG JOURNEYMAN .ELECTRd Cl AN i� a PAUL M BLA I S < , s 47 BEDARD AVE' �W DERBY NH 03038-4214 E 07I31./16 77351 r ® B 12/02/2013 09:36 FAX . 002/002 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lv 3 ` I Congress Street,Suite .100 _ ,1 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):Amore Electric,Inc. Address:65 Avco Rd. Unit F City/State/Zip:Haverhill, MA 01835 Phone#:978-372-5877 Are you an employer? Check the appropriate box: Type of project(required): 1. ✓1 I am a employer with 15 4.. I am a general contractor and I 6 New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. F71 Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' g 0 Building addition [No workers' comp. insurance comp. insurance. required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4), and we have no 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 are doing all work and then hire outside contractors must submit 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-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:Associated Industries of MA Mutual Insurance Company Policy#or Self-ins. Lic.M WMZ 8005862012012 Expiration Date: 6/15/2014 Job Site Address:grooks Gardner West Apt. 1160 Great Pond Rd. City/State/Zip:N. Andover, MA 001810 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-and enalties o perjury that the information provided above is trite and correct risty Forrest '` "��` Date. 12/2/13 St atW V. �k]O13LI�11t T31-0SUO' _. _.. Phone#: 978-372-5877 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#: f Date.. ..�... ,LORry TOWN OF NORTH ANDOVER PERMIT FOR WIRING �BgCHU96 d This certifies thatJ. d has pern fission to perform .. .:�� 1�. °... wiring in the building of ® �� ;. .................................... 1 �l �y ................................................... at � � � �� T�� -/ r North Andover Mass. ..... ... . ........`.. . ...... ......... ........ - jFee,:Z � ; ,,,,,,,,Lic.No°. .. ........L cruc..0 Ixscrox . Check# ei E E C k C.Own-weaR o1)Wa_jjac1Wetb*' official Use Only Pen partment ol3jpe Sepvjcg�,, .Wj Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 07 Rev. 11' ) leave blank-) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK :V!-ork ko be performed in accordance with the Massachusetts Electrical Cooe,(MEC).527 CN4R 12.00 PL E.4SE P R I VT INfNX OR TYef W4L TIOA,) Date: Y) �;3 Cit-v or Town of: ector" of Wires.- To the Insfi B% -,-1j)p)1CMion:he undersigned wives notice of his or her"Itmion to perfo the electrical work described below, Location kstreer& Nu't�)ber) - r" O\i ner or feriant 5 �70, Telephone No.(7 nee Is this permit in conjunction with a building permit? Yes F-1 No El (Check Appropriate Box) Purp6st: of Building Utility Authorization No. L.\i,,tino Ser.icr Amps Volts OverheadF_1 Undgrd❑ No.of Meters Service Amps Volts Overhead M Undgri:! ❑ No.of Meters Number of Feeders and AmpacitN L.Aoctiol"atu e�of Proposed Electrical Work: k Jerh5l Z/2 i Completion of itlefiollowing cable nigy be-voived by the Ins pactor o,of res ,-N.o.of Total No. of Recessed Luminaires 'No.of Ceil.-Susp.(Paddle)Fans Transformers KVA Ian.oJ'Luniinaire Outlets No.of Hot Tubs Generators KVA Above In- No.of Emergency Lighting No, of Luminaires Sivimming Pool f!rnd'. E� und. 11 Battery Units INO. QfReCepLaCle Outlets No. of Oil Burners FIRE D.of Zones No.of Detection and No. of Switches No.of Gas Burners Initiating Devices Nu. of Ranges No.of Air Cond. Total No.of Alerting Devices Tons Heat Pump NI _0_.­of Serf-Contai ned No.of Waste Disposers Totals: Detection/Alerting Devices.. I \o. of Dish,,-. Space/Area Heating KW Local E, Municipal E] Other Connection No. of Dryers Heating Appliances KW Security Svstems:* 0 No.of bevices or Eguivalent !�No. ofIvN ater No. of No.ofData Wiring; Heaters KW Ballasts Si gns No.of Devices or Equivalent Telecommunications wiring: Nio,. 14%dromaN%age Bathtubs No.of'�vlotors Total HP I No.of Devises or Equivalent OTHER: - 4tlaC17 additional detail if desired,or as required by the Inspector of Wires. Esi'miawdl \ ailie of Electrical Work: (When required by municipal policy.) \',01i" ,v suirc Inspections to be requested in accordance with MEC Rule 10,and upon completion. "SL:R_-*k,N-CECOVERAGE: Unless Nvai%ed by the owner,no permit for the perflon-nance of electrical work may issue unless ;h,c kcc-nsee pro"ides proof of liabilit,, insurance:;ncluding-completed operation"coverage or its substantial equivalent. Th.- . i Z� fl ,mdc! _-ijc:d c.z!( I iesthar such coverage s in force,and has exhibited proof of same to the permit issuing office. C i i r.(.k C)\1-_ IXSI:-RANCE [:] BOND [I OTHER El (Specify:) I certil)% under the pains and penalties ojpeijury,that the information on this application is true and complete. FIRM N.vNIE: tl*_Iia���_ -542,rvy LIC.NO.: Ar Signature L C.IN 0j: Bus.Tel.No I In the lice se 7 bell' e.9T. �Y" a Alt.Tel.No." Add "Per M.G.L.c, 147,s. 5-1-61,security work requires Deparrffient of Public Safem—S"License: Lic.No. 0\\*NF,R"SI.NSUR-kNCEWAB-,-ER: I am aware that the Licensee does not have the liability insurance coverage normally B".Inv signature below,I hereby waive this requirement. I am the(check one) owner ❑owner agent. 0\\ner k,cut t I PERVHT FEE: S Telephone No. Print Form The Commonwealth of Massachusetts Department of'InditstrialAccidents Office of Investigations I Congress Street, Sidle 100 Boston, MA 02114-2017 fvwfv.mass.gov/(`/l*(i Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):Lighting Retrofit Services Address:234 Ballardvale Street City/State/Zip:Wilmington, MA 01887 Phone #:978-988-7800 Are you an employer? Check the appropriate box: Type of project(required): I.Z I am a employer with 42 4. [—] I am a general contractor and 1 6. r_1 New construction employees (full and/or part-time).* have hired the sub-contractors 2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7. F-1 Remodeling ship and have no employees These sub-contractors have 8. [:] Demolition working for me in any capacity. employees and have workers' 9. E] Building addition [No workers' comp, insurance comp, insurance.$ required.] 5. E] We are a corporation and its 10.El Electrical repairs or additions 3.El I am a homeowner doing all work officers have exercised their I ].[:] Plumbing repairs or additions myself. No workers' comp. right of exemption per MGL 12.0 Roof repairs' insurance required.] t c. 152, §1(4), and we have no I 3.0 Other Lighting Retrofits employees. [No workers' comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContrac'to,rs 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-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Hartford Insurance Company Policy # or Self-ins, Lic, #:000350415 Expiration Date:04/13/14 Job Site Address: J/L�o_�­ �) .-_��� L,1,a) , , City/State/Zip: 001)0azLir 4�iA Attach a copy of the workers' compensation policy declaration page(showing the policy number,and expiration date)o,/i 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(to hereby certify under the gains and penalties of e�t ry that tl e i i t t 1 1! ormation provide above is true and-correct. e f //X A3 Si nature Datelture,L Phone#: Ll 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#: