The URL can be used to link to this page

Home My WebLink AboutInsurance Letter - Permits #11336 - 70 COURT STREET 1/2/2013 Date ./ . � b¢'f(LItD 76yo-; TOWN OF (NORTH ANDOVER PERMIT FOR WIRING This certifies that . . �� - �� •�' has permission to perform . . . . . •a wiring in the building of . . . .Ue 4 L• • �' • • • . q . . . . • • . • • • • at . . . . . . . . . • ,North Andover Mass. Fee . ,� . Lie. No. . . ELECTRICAL INS ECTOR Check# GE r 3 t commonwealth of Massachusetts Official Use Only Permit No. Department ®f Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICALo WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12. (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his ox her intention to perform the electrical work described below. Location(Street&Number) rt� � ` Owner or Tenant �..lL. Telephone No. Owner's Address 70 CC>u P F Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service�O Amps l / A0 Volts 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: Completion of the following table may be waived by the Inspector of Wires. No,of Total No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators 1 KVA Above In- .0 mergency ig tmg No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Detection and No. of Switches No.of Gas 13 urners Initiating Devices No.of Air Cond. Total No.of Alerting Devices No.of Ranges Tons HeatPump Number,Tons.....,,,,.KW.......... No.of Self-Contained No.of Waste Disposers Totals: Detection/Alerting Devices Municipal Other No:of Dishwashers Space/Area Heating KW Local❑ ❑ Connection g Appliances KW Security Systems:* Heating No.of Dryers No.of Devices or E uivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts - No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or E uivalent " OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value UVR-AGE: trical Work: 1�jC')U r (When required by municipal policy.) Work to Start: ts-i� Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C 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 F1 BOND ❑ OTHER ❑ (Specify:) I certify, cinder the pains anti penalties of perjaaq,that the information on this application is true and complete. FIRM NAME: . �� `JS LTC.NO.: - Signature/ ,, ter' Signature 2 LTC.NO.: Licensee: 3 �, 2 (If applicable,enters"exempt"j' the license number li Bus.Tel.No.: S Address: i' O ° /� `'L/ � rates Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires apartment of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAVER: 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 Telephone No. PERMIT FEE: $ Ci nfltra _.. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 wwiv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): Lft _� R Address: 1 � 14 City/State/Zip: 1 ��2✓ ' 1U' �/ Phone#: 66—s) 17 Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. [11 am a general contractor and I 6. ❑New construction Vmployees(full and/or part-time).* have hired the sub-contractors 2. I 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 me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL I L❑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' 13.❑ Other comp.insurance required.] *Any applicant that checks box#I 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 their workers'comp.policy information. I ani an employer that is providing iporicers'compensation insurance for my employees. Below 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify tinder the pains 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: uENERATOR APPLICATION i DATE: Z, LOCATION: OWNERS NAME: NGA GENERATOR kw � NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPR VALS* CONTRACTOR: Ili=-015 100 -p"A� �� PHONE NUMBER: 6b `oo a� ELECTRICAL GAS RESIDENTIA COMMERCIAL TEMPORARY LOCATION OF GENERATOR: + == L � - *ZONING DISTRICT: *CONSERVATION APPROVAL