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HomeMy WebLinkAboutInsurance Letter - Permits #11353 - 67 COTUIT STREET 1/11/2013 pp Date . .' TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform .Cf--. wiring in the building of . .�. . . . . . . . . . . . . . . . . . . . . . . . at . .�. t �? . .�. . . . .a.. . . .. . . . . . . . . .Aorth Andover, Mass. Fee 1 ic. No. . . . . . . . ELECTRICAL INSPECTOR Check# 6 (fonwwntvaahli of Ma6eaclut6effd Official Use Only 2.,parEnwd.1 im Permit No. y BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perrormed in accordance with the Massachusetts Electrical Code(MEC),527 C 12.00 (PLEASE PRINT IN INI.'OR TI'P,E / INF ION) Date:___ #c Cityor Town of: a �(� To the Inspector of Wires:By this application the undersigned gives otice of his or 4er intention to perform the electrical work described below. Location(Street&Number) v T c�— Owner or Tenant v.Telephone No. Owner's Address jL-y� 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❑ Und rd g ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Worlo 4 Com lesion ojthe olloivin table may be waived by the Inspector o/IPires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans o.of Tota Transformers KVA No.of Luminaire Outlets No, of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above )n- o.o mergency ig tag rnd. ❑ d. ❑ Bane Units No,of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No,of Switches No.of Gas Burners No. of Detection an Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers eat Pump umber ons � o.oSelf-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local Municipal Connection ❑ Other No,of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent o.o Heaters KW ater °'°f No,of Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP elecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: I••Aft- 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 cov ge is in force,and has exhibited proof of sre to the permit issuing7oice.CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) � 1Q /�Z � , I certify,under site ants a rd pelt�f(tie of erjrrry,tl qt the it: rnratiotr on t rls appl call r is true anti om eta' FIRM NAME: v 6 GfC�c. (C 66 LIC.NO.e Licensee: yAe h �h 4 Signature _ t LIC,NO.: (If applicable,ens "exem P,in the license number/i } > / r Bus.Tel.No— Alt.Address: Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security w requires Departnient of Public Safety"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 a eat. Owner/Agent Signature Telephone No. PERMIT FEE: $ `r��1/1)_3 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 UV www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le0bly Name (Business/Organization/Individual): 0,1� �/Y�C� 1 �c t C Address: `� C� i Cke a2 t►�5 ,�/� n City/State/Zip: f qo Acy-?III �V t,� Phone Are ypi an employer?Check the appropriate box: Type of project(required): © I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors El am a sole proprietor or partner- listed on the attached sheet. Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for mein any capacity. workers'comp.insurance. 9. Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑ Other my applicant that checks box#r must also fill out the section below showing their workers'compensation policy information. lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. tm an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. ' surance Company Name: ilicy#or Self-ins.Lid.#: Expiration Date: b Site Address: City/State/Zip: :tack a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a Le 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA for insurance coverage verification. 'o hereby certify zcnil tl p sjn penalties ofperjury that the information provided above i trice and correct. mature: -7 Date: ��t.- one#: 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): I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Persan:` _ Phone#: