HomeMy WebLinkAboutWiring Permit - Correspondence - 410 GREAT POND ROAD 2/19/2014 Date...........................................
t
or,',jORTh;'ti TOWN OF NORTH ANDOVER
m9 PERMIT FOR WIRING
88ACMIusb
es that ... .....
This certifies ........
has permission to perform ......•...
wiring in the building .... s
at ...
' ....,North Andover,Mass.
Lic.No. r.. ...... cm
Fee.•., Er cr[ucai INse m
Check#
I1, � -
W -
�.,,�,n. +• ' l • � � • 1. •rN It.0 ,na � !tY.*r-1
a
•
I
) s:t x [ r x If�11 1`- '�1 I 1 U I a t)tr It" l r, a.. r r. l c-.► )cY - 1,
1 _
tt 1'
1 R _
r
Y
1 c r..:-.. rnr:tom_ • - ) •_-•• , ,,', -
t
i< sa.•t s rr a
t t i 1 t l vrv:.
r .rr ittll s � s ll 3 f a i
.I _
i fit:.
it r 4t= i C:tx - 11i 't11f I �
4. 1 r ) • � I all ..YI 1 l � , Il F
r•Ir/f• ` I 1 `f 1.., =+..
It,
J I 4I
i t • «. , �t 1► ,.III i^ " I' '
� 1 � • rl ) - :1)/ I Irll ►r.lilt 1 1 t'.
- i - i• I:-. I I 1.t1fl Y Ir, it )_-
It H i rllu/ :+�I t I a .q Irt ►i .+. ... "/l 4- t:t' MI' i•t I...�, - .•1 :ill i..:
Nil 'M: •T !' ( ,� .:ul . / )._11 •i.un_• a u►:
r -
•
1 1 l:-1 t • ♦: �' II- t 1 :lt It. ,tr► ►r
1 K i • ti < ,:�1 11 .i11..1/i :Ifl 1 .. :1� t) . _
•Je RI -
�� .y �
The Commonwealth of Massachusetts
Department of Industrial 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/orgamzation/Individual): G l C('_
Address: 2(/ � r r'
City/State/Zip:_ C Phone#: (�9j`
Are y u an employer?Check the appropriate box: Type of project(required):
1.R I an a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. El Now construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. E Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers'comp.insurance comp.insurance.1
required.] 5. ❑ We are a corporation and its I0.❑ 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.❑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.
$Contractors 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:/��C%)J f r1372 / / <'c' /OLE
Policy#or Self-ins.Lie. Expiration Date:,
Jab Site Address: �/ / z `� P t/� �` City/State/Zip: � oUE' A)
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby �under the pains and penalties of perjury that the information provided ove is true and correct
afor Si e: / G'" Date:
Phone#: 2, /7
Official use only. Do not write in this area,to be completed by city or town official
City or Town: PermitlLicense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
#�.:COMMONWEALTH OF MA$SACHt1SETTS
Al® ® ` ®
ELECTRICIANS
ISSUES THE FOLLOWINGIGENSE
REGISTERED MASTER ELECTRIC-IAN.•
BUD`[#Y ELECTRIC I N C �
V°1 NGENT B LANdRS JR
24 E CfRi_
GDLGAT
r yLu
N; AkbVER MA 0 1845 1807 " Y
12017''Aii... 07/31/16 44863