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Home My WebLink AboutInsurance Letter - Permits #12832 - 14 COTUIT STREET 10/20/2014 Date.. .... .... ..... ......... E �NoaT�q TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING CHU A This certifies that -?��,L ......................... .................................... has permission to perform ..... ....... ................................... wiring in the building of ............I........I..................... .................. at -11.. .................................No4 Andover,Mass. .................. ................ ............ Fee—.`.", ..........Lic. No................... ............ .' . ... h*L'E-C-T-R-'IJ!.L INSPECTOR Check# Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL. WORK All work to be performed in accordance with the Massachusetts Electrical Code WQ 527 CM 12.00 (PLEASE PRINT INNK OR TYPE ALL INFORMATION) Date: l o A-r7 l City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned givesnotice of his or her intention to perform the electrical work described below. Location(Street&Number) rV+U � t Owner or Tenant L'tS h- c gg Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building c LOCI l "o Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters v 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 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- ❑ o.o cy 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 No.of Detection and Initiating Devices g Tons 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 1 p Totals: "" """""'"'"" ' "" ' ""'" Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent---- No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent " OTHER: a'e`,r'L1G a Attach additional detail if desired,or as required by the Inspector of 07res. 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) Icertify,under thepains andpenalties ofperjury,that the information on this applieation.'s true and complefe. FIRM NAME: " LIC.NO.: P-7 (n Licensee: Signature- AZ --� LTC.NO.: (If applicable, 5nter "exempt"in the license mb line.) Bus,Tel.No.: ` o(101- Address: to , _ ' 0 Alt.Tel.No.: *Per M.G.L c. 14 ,s. 7-61,secigity work requires Department o Public Sa ety"S"License: Lic.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 PERMIT FEE: $ ` Signature Telephone No. The Commonwealth of Massachusetts - De-paihnent ofIndus1r1a1 Acc!d&fs Office of lnvestlgations 600 Washington Street ;Boston,MA 02111 vipmmass govldla Workexs'Compensation Insurance Affidavit:]Build.ers/Contractora/Electriclans/PMnbers A Reant Worznation Please Prim Le I'b Name(Business/Orgadzationitndzvidual): 2 K'��!� Address: 'e C/ R City/State/Zip;�'� (��t,i `�� a Phone#: .Are your an,employer?Check the appropriate]box: Type of project(required): 1.[� I a employer with. 4. ❑I am a general contractor and I 6, []New constraction f e ployees(falland/orpar�time).* have hire d the sub-contractors 2. am.a sole proprietor or partner- listed on the attached sheet. 7, ElRemodeling ship and'have no employees These sub-contractors have S. [l Demolition working forme in any capacity. workers' comp.insurance. 9. ElBuilding addition [No workers'comp.insurance 5, E( We are a corporation and its 10.❑Electrical repairs or additions xequired.] officers have exercised.their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.[(Plumbing,repairs or additions myself.[No workers'comp, c.152,§1(4),andwehaveno 12,E Roofxepaixs insuraucerequired.]7 emplo1. yees. [No workers' n l Other comp,insurance required.] NAny applicautthat checks box#1 must also fill outthe section below showingtheir workers'compensation policy information. T'Homeowners who submitihis affidavit indicatingthey a're doing allwork and then hire outside contractors mustsubmit anew affidavit indicating such. tContractors that cheolcthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an em Below is the Polley andployer trzat ispi ovirling worXcers'compeizsation insurance for ay employees. jolt site information. Insurance Company Name:_ Policy#or Set£ins.Lie.#: Expiration Date: Job Site Address: 1 nJ t -pity/State/Zip- Attach �/� /�—�;�. .A-t`ca.ch a copy of the workers'compensation-policy declaration.page(showing the policy number and expiration-date). Failure to secure coverage as regyneclundor Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a Rn e up to$1,50 0.00 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 ills nse_c exage verification. X do hereby cer fy-uiider azns an yenalt es ofperjuiy that tree information,provided above is ue and c rect, - Signature: Date: f� a� Official use miry. Do not write in thfs area,to be completed by city or town official; City or Town, Permit/License# Issuing authority(circle one): 1.Board of Health 2.BuMingDepartment 3.City/Town Clerk 4.Electricalluspector S.Plumbinglnspector 6.Other Contact Pers on: Phone#: i ::COMMONWEALTH OF MASSACHUSETTS . . B0ARD W EL EC C1 ANS I SSUES .THE FO_L0 4 W L VftE AS >A REG, J0URNE'MAC N ELECTRI z FQRREST R CURRIER 'W A'L 125 HILLDALI ST Iv }� HAVERHILL MA 0'1832 38.322 $ 27658 07/1 16