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Home My WebLink AboutWiring Permit (s) - Correspondence - 1160 GREAT POND ROAD 8/29/2013 q � Date �....... R,TM� TOWN OF NORTH ANDOVER PERMIT FOR WIRING ±j ��eACHUg� This certifies that . *G,�,�. .. .�,`.'C�! 1"`� :'G.1 �'I e has permission to perform s wiring in the building of•,•• ....... . 5 . .••..... . •..................• a North Andover Mass. at ... • Fee. ... .....•..•...Lic.No¢....... ....... .....M .•• ...•.•.......•.... ..•..........•.........•..•.....•... ELECTRICAL INSPECTOR E Check# 4 (f1mmonweakh o1)Wa63ac4uJe1b Official Use Only 2e artment o 5ire serviced Permit No. C - �> Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT 1'O PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MBC),527 CI�TR�k¢o (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) dwee City or Town of: . 4 0 A 6 u Cam' To the Inspector of Wires: By this application the undersignedggives notice of his or her intention to perform the electrical work described below. Location(Street&Number) /�� Owner or Tenant I5j it D D e-S CC-�0 D 1. , L /-)C Telephone No. 9 2' "723,J-L A J- Owner's Address ,� 1 rV� 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 b New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity �c Location and Nature f Proposed Electrical Work: K-p L 10 t=, 'Ai Al 6L ® M �R g' Completion of the following table may bY waived 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 ig mg rnd. rnd. Battery Units T No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No.of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total No. of Alerting Devices Tons g No. of Waste Disposers Heat Pump Number Tons KW No. of Self-Contained . Totals: ""' ' """"""""""""""""""""""""""""' 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 XW No. of No. of Data Wiring: Heaters Signs Ballasts' _ No.of Devices or Equivalent No.Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: ___ of Devices or Equivalent OTHER: Attach additional detail if desired.or as required by the Inspector of Wires. ` Estimated Value of El ctricgl Work: /' D (a, (When required by municipal policy.) Work to Start: F 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. Thea 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 pains and penalties ofperjury, that the information on this application is true and complete. \ FIRM NAME: ' ti{ �ZZC i2i C� CC, LIC.NO.: 32 7 3 lc SitN/ Licensee: (;r;rr [e�- 'Ti 1.n%.r� Signature` � �'- -� LIC.NO.: (If applicable, enter "exempt"in the license number line.) Bus.Tel.No.: l Address: L t�l r%pi^t W A-�e C'I-l.Jt.. - M4 0�/ �9 Alt,Tel.No.:C�t')-/-'-9 -3�G1 *Per M.G.L. c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lid.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�oneF-lwner ❑ owner's a ent. Owner/Agent T FEE. S Signature Telephone No. i i The Corro2onwealth of Afagsachusetts Departnient of Industrial Accidents ��o. •- t?~N Office of Investi:a atIons j 155 600 Washington Street Boston,MA.02111 �y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibiv Name(Business/Organization/IndiAdual):��i4dLvjsb,(J L-_LtC,-0&1 C/-j Address: Erg;pr,1'r t,J City/State/Zip: C:-kal 0 (� Phone : (Q 17 ��O Are you an employer?Check t e appropriate box: L g I am a employer with 4. ❑ I am a general contractor and.I Type of project(required): employees(full and/or part-time), have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [] Remodeling ship and have no employees These sub-contractors have S. Demolition working for mein any capacity, employees and have workers' [No workers' comp, insurance comp.insurance.# 9. ❑.Building addition required.] 5. [] We are.a co "oration and its 10.7 Electrical repairs:or additions 3,❑ I am a homeowner doing aIl work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp, right of exemption per MG!, 12.❑Roof repairs insurance required]t. c. 152, §1(4),and we have no 13.❑Other 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. 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 mamber. lam an employer drat is providing workers'eompensrzfion insurance far nzy employees. Below is the policy and job site information. /� / rn Insurance Company Name /7/M !d l(duct/ _Z�s, 0, Y Policy#or Self-ins, Lic,#:M �� d�`, Expiration Data: b 5 &j Job Site Address: l(D O kY_�_'F City/State/Zip: !J` /�J•/�,� p[gOj� Attach a copy of the workers' compensation policy declaration page(showing the pointy 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 i of up to S250.00 a day against the violator. Be"advised that a copy of this statement may be forwarded to the Office of j Investigations ofthe DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperfury that t/ze information provided above is-true and correct SiQrtatur �ell -�.aG ��, Date: Phone#: 1 7 Official use only. Do not write in this area, to be completed by city or town official i i City or Town: Permit/License# Isst L^ A-mthor lty(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Pho �. ne r, i Division of Professional Licensure: License Search Page I of I The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES Check a License Cheek A Pi-ofessional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency SEARCH CRITERIA Lore.., Profession:Electrical Business REFERENCES& Business Name:beginning with wi(tiamson RELATED INFO Business City:chetsea NEW SEARCH Disclairner Regarding Website License Searches LIC. LIC. BUSINESS LIC. LIC. TYPE BOARD NUMBER BUSINESS NAME CITY/STATE STATUS Enforcement Process I Master Glossary Electricians Electrician 15502 WILLIAMSON ELECTRICAL CHELSEA,MA Current Glossary of License Status F6 —COMPANYINCO RA-F Codes Your search has resulted in I licenses Mora... Thepage above has been generated by the Division of Professional Licensure web server on Thursday,August 29,2013 at 9:38:00 AM. @ 2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us/public/pubLicRange.asp?profession=Electrical—Business&bu... 8/29/2013 Date.... ........................ OF NORTH TOWN OF NORTH ANDOVER ►- p PERMIT FOR WIRING g8�c►mug� Thiscertifies that ......... ir....................................................................................... .. has permission to perform ... t� .� �r.....�c.42K.2. :...... z .. ........... wiring in the building of...... .. .......s ..r ................................ at ........ „::)......,North Andover,Mass. �f $ 0 s Fee Lic.No. ......... .....� . � A .................. Check# Commonwealth of Massachusetts Officinal Use Only 1 Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Rev. 11/991 leave blank UVI 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: 64gez- ll / City or Town of: Nyf.�� ,v,=r .} 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). "2 61ed { ❑i/ zz%ik Owner or Tenant , �� ,/ Telephone No. Owner's Address &6a �r �� f ed A,-el Via,' t it � � 1--,t4 e%oq.i" 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: � � ()lC Oi'kl Completion of theffollov4ng table may be waived by the Ins ector o Wires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of f ITootta all Transformers "f No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above ❑ n- ❑ o.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No. of Switches No.of Gas Burners o.o Detection an Initiating Devices No.of Ranges No. of Air Cond. Total No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerti Devices No. of Dishwashers S ace/Area Heating KW Local ❑ Municipal ❑ Other p °g yCsonnection No.of Dryers Heating Appliances KW Security f Devices or Equivalent No.of Water o.o o,of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Eauivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: 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 a undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE FT"BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical World`` -,2(;i t)6 . (When required by municipal policy.) Work to Start: ! "plc Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify, under the ins and penaldes of perjury tha the informtrtion on this application is true and completes FIRM NAME: �pdi C is �t�rlc 1/<tc/ i LIC.NO:: Licensee: '�/t 14C-S 1�. �� ' Signature LIC.NO.: (If applicaPINSURA:�NCE rpt"in the license number line.) Bus.TeL No.• v��1 -a r� Address: ? A d9 Alt.Tel.No.: V OWNERWAIVE : 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 Signature Telephone No. PERMIT FEE: $ „ 7 r� tm� &7- L� 7 1y `le G /S-: 7 7- / n 'Tp ozly moo& 14f Val D. INSURER'S AFFIDAVIT AS TO WORKER'S COMPENSATION INSURANCE Alliant Insurance, 131 Oliver St., Boston, MA 02110 [Name,Address] am: an authorized representative of Insurance Company [Company Name] f� (a producer'in the voluntarymarket�f an authorized agent of Travelers Insurance Company(an agent in the voluntary [Company Name] market, authorized to sign on behalf of a producer)t F�an authorized signatory of the the Prime Contractor(an insured [Company Name] of a producer in the involuntary market pool)t Flan 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 Highway id-11rages of the Highway Division of the Massachusetts Department of Transportation,. Sign ' f� AStantAccount Representative Title COMMONWEALTH OF MASSACHUSETTS On this 19th day of July ,20 i1before 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 doe�i ment are truthful and accurate to the best of their knowledge and belief. Notary INN [Printed Name] rl OY Public lic MA SACHUSETTS Dn Expires 0 1 8 NICOLE ROY Notary Public COMMONWEALTH OF MASSACHUSETTS My Commission Expires July 20,2018 EOCO A producer is an insurance company that provides insurance policies directly,not an insurance agent. 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 Fold,Then Detach Along All Perforations T COMMONWEALTH OF MA.SSAGHUSETTS:.; -; ;QOARb O ULECTRICIANS ISSUES THE .FOLLOWING L ICENSE AS A.'``, >° REGISTERED MASTER:ELECTRICIAN : ;a r iz P.O.W.ER" LINE CONTRACTORS INC ES R :DAGL� W` PO BOX 26:6'.:, ;x :J ;WOBURN m 01888-0059 17o87 A ° 07/31/t:6 70005 /rim J/ � r / fly�j�J / a// / / r ! r` y r ✓h✓' /B Rj�//��%r / 1, - '� J�� ;�/D�i/i� "/ /��' �� /r� ✓''/%%/� �Ir u r � r / I gGG 4 / e llm Ava � 1 �a it/emu r /! r 'I G G ��''� YV I ull' uuiilm �� ICI ��II i°;IV a uuuuu a Y„ rr /' i i il�u