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Home My WebLink AboutInsurance Letter - Permits #13136 - 134 CROSSBOW LANE 3/3/2015 f r Date :........... ............................ OF NORTH 4ti TOWN OF NORTH ANDOVER PERMIT FOR WIRING O s �' p sACHUg� x Thiscertifies that ...::: .......................................................................... ... ........................ has permission to perform ,., f wiring in the building of ...k. ................................................................ at . ,.. ...... .........:., orth Andover, ss. Fee.:... ..................Lic. No. ELECTRICAL �� i INSPECTO ( Check# r Commonwealth of Ma-machuietts Official Use Only Permit No. , > 1��' Apartment o f Jim Service Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank) 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: -j 3- t-i City or Town of: tl, 14 MQn 1/�t g.- 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) Owner or Tenant yT Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building P8,r, F40w y Utility Authorization No. Existing Service leu Amps 040Volts 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: i N 5 ro Al c D r0 OtJ /lt d tf- 0/y ttq-, z Oyw- Completion o the ollowin table maybe ivaivedby the Inspectorof 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 j Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Batte Units No.of Receptacle Outlets 3 No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices � No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices 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 l Connection No.of Dryers Heating Appliances KW Security Systems:*No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Si ns Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 4620 _ (When required by municipal policy.) Work to Start: �� -�, In pections to be requested in accordance with WC 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:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: Signature j�% SIC.NO.: p� (Ifapplicable, nter "exempt"in he license number line.) Bus.Tel.No.: , Address: v T ''T— k t4� �f 0� G�21 Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires bepartment of Public Safety"S"License: Lie.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 Signature Telephone No. PERMIT FEE: $ — � J i O The Commonwealth of Massachusetts Department oflndustrialAceidents d 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 gib Name (Business/Organization/Individual): z1,At r 7/1 A(c7 vT 2 2/ Address: )z A ff 1AR v H i - 5 l City/State/Zip: Afir - d-C-- N& DZ ? Phone#: (y< L— -4 gg -g Are you an employer?Check the appropriate box: Type of project(required): IQ employer with employees(frill and/or part-time).* 7• Q New construction 2. am a sole proprietor or partnership and have no employees working for me in 8• modeling any capacity. [No workers'comp.insurance required.] 3.�I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q 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. 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 number. I am an employer that is providing workers'compensation insurance for my employees. Beloly is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 certify u der the pains4n pen altie of per jury that the information provided above is tare and correct. Si nature: rr Date: - Phone#: t[i 17.V, �J�`4 Official use only. Do not ivrite in this area,to be completed by city m-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#: COMMONWEALTH HUSETT OF M $ pG :j }: ELECTRICIANS : .; l SSUES THE FOLLOW I tG L I CEN t 1 AS A JAG JOURNEYMAN ELEC�RI G� cc f� GAETAN0 P ERR I \ ' 38 VAN >Bi2UNT-ST iYD:£ PARK P1A 02136 33"� 40668 10139...8 .., ... 0 /3�./.}°� ..