The URL can be used to link to this page

Home My WebLink AboutInsurance Letter - Permits #12489-1 - 196 COTUIT STREET 7/15/2015 Date, ................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING . .W .......... BgA CHU This certifies that ...... ................................................................................................................... has permission to perform ...................................... ....... wiring in the ng o build' .... .............. .................................... ....... ....... ....... at Nort4 Andover,Mass. ...... ........... .. ........Lic. No.,ic'LIV? ...Fee.... Check# Z4 Commonwealth of Massachusetts Official Use Only � )Jl Permit No. Department of Fire Services Occupancy and Fee Chocked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07) (leaveblank) 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 PMT1NJN1(OR TYPE ALL INFORMATION) Date: 7 — Is — City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intentio form the electrical work described below. Location(Street&Number)_ C�, G U,I!E Owner or Tenant ul)c T P Telephone No. Owner's Address R-M t Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building�T)uc) t I1 e' Utility Authorization No. Existing Service Amps Volts OverheadF] UndgrdF] No.of Meters New Service Amps Volts OverheadF] Undgrd [I No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:�'P*T-'C)0 -.1 �A Q c VA Completion of the fol owing table may be ivalved 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 o In- n 0.0 Emergency Lighting grnd. grnd. ❑ 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 No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons Heat Pump Number I Tons I ICW No.of Self-Contained No.of Waste Disposers Totals: 1..........*.............*1..........*............ Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑F1 Municipal F1 Other Connection No.of Dryers Heating Appliances KW Security S Dystems:* No.of evices or Equivalent No. of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.o;%Igvices or Equivalent No.Hydromassage Bathtubs No.of Motors Total UP Telecommunications Wiring: No.of Devices oi-Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Elec, 1cal Work: C (When required by municipal policy.) Work to Start: I V-0 L;Xnspections 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 CONE: INSURANCE P BOND 0 OTHER n (Specify:) I certify, under thepains and penalties ofpeijuiy,that the liffiorniallon on this application is true and coin e pl te. FIRM NAME: LIC.NO.: Licensee: Signatur i LIC.NO. (Ifapplicab e, enter "exein "I he lice e nit ber hni�6L I p� Ae 0 *Per M.G.L c. 147,s.57-61,security work requires Department 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)[I owner E]owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ '' The Commonwealth of Massachusetts _. . ' Department of lndiustrialAccidents Z Congress Street,Suite 100 Boston,MA 021.74 2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractor, s/E�ectricians/'lnmbers. TO BE FILED WITH THE PERM[TTING AUTHOIUTY. Please Print Le 'bl A '•licant Information Nalne(Business/Orgahization/Individual): 14 Address:C7Z I r\ Phone 4®ctJ tv City/State/Zip • :. .:. .. : ...._x.., n ; _ Are you an employer?Cheel., e appropriate box: Type of�projeet(required): em to ees(Rill and/or part 7. ❑New construction I-�am a employer with P y 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. �Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3. I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Building addition 4.F]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11. lectrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole biYi repairs or additions proprietors with no employees. 12�[�Plum. g p 5.❑I am a general contractor and Ihave hiredthe sub-contractors listed onthe attached sheet. 11 Ej Ro6frepairs These sub-contractors have employees and have workers'comp.insurance.t 1<1 Other 6.❑We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and ive have no employees.[No workers'comp.insurance required.] *Any applicant that cheoks box#1 must also fill out the section below showing their workers'compensation policy information:, 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 of not those entities have ontractors have employees,they must provide their workers'comp.policy number. employees. If the sub-c X am an employer that is pr'ovidingworlrers'compensation insurance for my employees. -Below is file policy andyob site information. Insurance Company Name' Expiration Date: Policy##or Self-ins.Lic.#: t1N 6 '®� ( City/State/Zip: Job Site Address: compensation policy declaration page(showing the policy number and expiration date). Attach a copy of the worker ulb up to$1,500-00 Failure to secure coverage as required awell as civil ivier ilpenalties in the form of a ESTOP 25A is a criminal violation ORDER and a fine f up to $2550.00 a and/or one-year imprisonment, day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certify unde tliepains andpenalties of perjury that the information provided wave is true and correct. Date: Si afore: Phone##: Official use only. Do not write in this area,to be complet d by city or town official. City or Tovvn• Permit/License# Issuing Authority(circle one): i 1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person: I' BOA b � F 1 E CTC'11 C,I�.hJS 1SSU! ; tHE FOLLOtJINC LICENSE AS JOURNEY�anl2 ECTRICIACJ ' a KEV'b°N W HOPK I N 27 HUNT POND .Rp w� Vj a,IJI�ptJh1 < NH .03873 ?14,1 3596 a At E 07/31/16 7-4034 . ....., .,.ram d ,e f�