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Home My WebLink AboutInsurance Letter - Permits #12646 - 67 COVENTRY LANE 9/4/2015 Date.... .... I...... ......... OF NOHTF�� o;� : .'• °o� TOWN OF NORTH ANDOVER '- PERMIT FOR WIRING 83ACHU5� This certifies that ...... ...'. ................. ...: ?.E..... : .y.:°..................................................... has permission to perform ......... ... :....................... ...... ... ........................................ � 8 wiring in the building of.......:: ° .......... ........................................ 7 at i glu-i nt....�1.-j........ ...................North Andover,Mass. Fee.L..d....................Lie.No. r'i � > --- k ELECTRICAL INSPECTOR Check# I Commonwea&o f//laieachujelb Official Use Only cc'yy Permit No. 2.p.rt.a 013ire Serviceb 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 TYP ALL INFO TION) Date: Z""� City or Town of: e Y 0 V�� 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) I r—,O y 'n L Z 1 q)-)e Owner or Tenant P J/l�Vl K d"Yl e r Telephone No Owner's Address �/� 7, 7�a� 59 ` Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building R::e 0,hQ Pvt C P Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity t " Location and Nature of Proposed Electrical Work: eCd Y1 e'C c l CO oIPhYr,!" plus, , Completion o the ollowin table inay be waived by the Inspector of Wires. No.of No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers K Al LL'r No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o Emergency Lighting { No.of Luminaires Swimming Pool rnd. rnd. ElBatte Units t, No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones of No.of Switches No.of Gas Burners No. InDetection and Initiatin Devices Ttal No. of Ranges o.of Air Cond. T o ons No.of Alerting Devices No.of Waste Dis osers Heat Pump Number Tons KW No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P Connection Dryers Heating Appliances KW Security Systems:* No.of Dr y No.of Devices or Equivalent No.of Water Ku, No.of No.of Data Wiring: Heaters signs Ballasts No.of Devices or Equivalent No.H dromassa a Bathtubs No.of Motors Total HP Telecommunications Wiring: y g No,of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: ,�'(1'`0 __ (When required by municipal policy.) Work to Start: yv, ,C';6(" Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COV GE: 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:) /113 A 6 fv d j2 1 I certify,under the pains andpenalties ofperjury,that the infornrad on this application is true and complete. FIRM NAME: `�^ yn L ex)h,7 r LIC.NO.: Licensee: Signature LIC.NO.: (Ifapplicable,enter "exempt"in t e license numbe line.) Bus.Tel.No.: Address: c�( Ct ®l l Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security wor requires Department of Public Safety"S"Lice se: 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 A, Department o.f Industt ccdents ( . v "'�` 61 Office of Investigations 600 Washington Street . ' '' Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contras ors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): t 1 Address . ., c� �,. � d �� : �" Phone#: ✓' n ,� ,� . City/State/Zip: kk �. tI Are you an employer? Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and I 6. ❑New construction part-time).*employees full and/or .* have hired the sub-contractors p y ( p listed on the attached sheet. ❑ Remodeling 2. 1 am a sole proprietor or partner- These sub-contractors have 8. El Demolition ship and have no employees working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their right of ion per MGL 11.❑ Plumbing repairs or additions exemption 3.❑ 1 am a homeowner doing all work g p p myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] f employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am art employer that is providing workers'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 rrn r the pains andpena dies ofperimy that the information provided above is true and correct. p me•µ r "" .�, Date: Signature: 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 Clerk 4.Electrical Inspector 5.Plumbing Inspector G. Other ® • . ® Mq ��OH[tSE�S LtRIC1ANS 1 SSUES A . .. 7HE EOLLOWI INFO' I CENS� JOURIVEYMq ELECTR LE0' SR,. ... 4 T DEXTER 5T` ' a 1844- 541g 81 .. 07/3]f 16 - - 6444.1 ` Date Town nf North Andover Your permit has been sent back to you for the fmUovvingneasons:. 1\ Cheokannountinoonent ' 2\ No copy of current license _________ 3\ insurance Binder not on file or expired ________ 4\ No Workers' Compensation Insurance /Ufadavit Form Please call with any questions Q78'688-9S45. Pax 978-688-9542 Workers'Compensation Form and Schedule of Fees can be found on the Town of North Andover VVebxite under Building Department. Mailing Address: IG0O Osgood Street, Building 2[L Suite 2035, North Andover, K4AO1845