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Home My WebLink AboutInsurance Letter - Permits #13256 - 37 COURT STREET 4/24/2015 Pti Date.... .' .... NORrh TOWN OF NORTH ANDOVER PERMIT FOR WIRING gACHU5� i This certifies that .......... has permission to perform � ° l Al - wiring in the building of............... . >U .,...-.;........E..:' ::. at p As North Andover Mass. ,.. , Lic No ELECTRICAL INSPECTOR Check# k Official Use Only Commonwealth of Massachusetts Department Fire Services Permit No. A& Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rcv.iw] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NIEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /—//z '-I/ City or Town of: NORTH ANDOVER To the Inspector of Wir�s: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 3 -1 COUV-� S+ Owner or Tenant iC,,,,v C- -:J-C'S&-VP Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes 2r No D (Check Appropriate Box) Purpose of Building tX&)!Nu VAA,\.* k Utility Authorization No. Existing Service_ Amps volts OverheadF] UndgrdF] No.of Meters New Service — Amps Volts OverheadFl TJndgrd [I No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1900 7 c)6j, . Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above [I In- EJ o.of Emergency Lighting grnd. ❑ grnd. Batter Units No.of Receptacle Outlets l No.of Oil Burners FIRE ALARMS No. of Zones No. of Switches No.of Gas Burners No.of Detection and Initiating Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices Heat Pump -VK .......... No.of Self-Contained No. of Waste Disposers Totals: I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ippl[I MunicConnectio rl other n No. of Dryers Heating Appliances KW Security Systems:* � No.of Devices or Equivalent No. of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.or%lgvjces or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP--]Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail it'desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 1000 (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 covyage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURIANCEE] BOND F1 OTHER 0 (Specify:) I certify, under the pains and penalties ofpeijuiy,that the information on this application is true and complete. FIRM NAME �,c-crj,' (DeC_tV-.-C— LIC.NO.: Aa,O-c,a.-0 17 Licensee: �X-te-- X I CC Signature_ LTC.NO.: Q)70),7 (If applicable,enter ..."exempt"in the license number line.) Bus Tel No 6 n Z3/ 0W Address: I�A - ,a kz-" sc\,U so Alt.Tel.No.: KV *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. I 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 0 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE.- $ ❑ 2012 Massachusetts EIectrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the-.provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that-Vvas "in effect or existence"during the qualifying period beginning on August 15,2008 and extending'through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note: Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass IN Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION• Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: ZL r � Inspectors Signature: Date: FINAL INSPECTION: Pass Failed Re-Inspection Required($.j ❑. Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts f Department of Industrial Accidents a , I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Na1ne (Business/Organization/Individual): t1 C_Q V& Address: �- City/State/Zip: SC.y � US ✓v v , Phone#: 23 (' 0 Are you aa_�ployer?Check the appropriate box: Type of project(required): )IF l am a employer with employees(full and/or part-time).* 7. El New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in g• ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no 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. $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. 'l lain an employer•tliat is providing worlrer's'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Co Policy#or Self-ins.Lic.#: a Expiration Date: Job Site Address: ` City/State/Zip: n A VV� _ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c ains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone-#: 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#: