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Home My WebLink AboutInsurance Letter - Permits #13315 - 67 COVENTRY LANE 5/18/2015 t ` Date .................... i OF V&ORTlI,�O TOWN OF NORTH ANDOVER o� �� PERMIT FOR WIRING t H �etl t 6 ..l.,,....t. .�.... �, ,Y.... �. This certifies that .. has permission to perform ... ........................ ........... . wiring in the building of....... i'` �" b�"" r _ x North Andover,Mass. at a Lic,No. r " Fee ....... a ELECTRICAL INspactox k f Check# f — Q�/ Official se Unl, � (_•./�ommonweaGd z o�Mw.4ac"alb } P ermit No. ,. "- .,LJeparfinerzl o�...tire�erviceo °. —" � pancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONSV071 leave blank -` APPLICATION FOR PERMITTO PERFORM ELECT ICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),52 CM 12.00 . (PLEASE PRINT IN INK C1R TY E ALL INFO TION) Date: lc ..�� City or Town of: )v�C11 c� To the Inspector of Wires: By this application the undersigned gives not' ,eof his or heinent'on to perfoMorm the electrical work described below. Location(Street&Number 0 ; 1 .�� Telephone No. Owner or Tenant I permit in conjunction with a building Owner's Address , pe j rmit? Yes ❑'. No ❑ (Check Appropriate Box) s this Purpose of Building 11)tiiitPAutlio'3zation Na Existing Service Amps / Volts Overhead ❑. UadgrdEj No.of Meters New Service Amps / Volts Overhead❑. Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed lectrical Work: Com letion of the allow i table may be waived by the Inspector of Wirt No.o Total No.of Recessed Luminaires No:of Cell.-Susp.(Paddle)Fans Transformers KV'A No.of Luminaire Outlets No.of Hot Tubs Generators KVA °. a Above In- o.o. mergenry ig ting No.of Luminaires Swimming Pool rnd. rnd. Batte Units. No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones o.of Detection and No.of Switches. No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Totals tuber Fans KW o.of Self-Contained Detection/Alerting Devices Municipal No.of Dishwashers Space/Area Heating KW Local❑ ConnectionSec Other Heating Appliances KWutih'Systems-* No.of Dryers No.of Devices or Equivalent No,of Water KW No.of No.of Data Wiring: : . Heaters signs Ballasts No.of Devices or Equivalent: elecommunications Wiring No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: .9ttach additional detail if desired or as required by the Inspector of Wi: Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unb the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. Tht undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. : .. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER El (Specify:) I certify,u»der the paint and penalt`es of perjury,that the information on this application is true and complete. FIRM NAME: /. tit r� Iv �,G - LIC.NCI.: f pp rent -exempt f the � � ""� �� LlC°.NO.: Licensee: l 2 Signature L a licable e p ' lice e m r line.) Bus.Tel.No.. i� ' ,S.��t e Address: 6)N C) ✓,�21�'/ lawn Alt.Tel.No. "Per M.G.L.c` 147.s. 57-61,security work requires Department of Public Safety"S' License: Lic.No. OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the liability insurance coverage norma[1 required by la\N By my signature below;I hereby waive this requirement. I am the(check onej❑owner ❑owner's ag Owner/Agent PERMIT FEE: S Signature _ Telephone No. The Commonwealth of Massachusetts Department of Industrial Accidents ` Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbelrs Applicant Information Please Print Legibly Name(Business/Organization/hidividual): "7 t LLG1 Address: AU f 6F09 X City/State/Zip: 4wifeQ, /9" &M Phone#: 91 g Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with__1___ 4. ❑ I am a general contractor and l employees(full and/or part-time).* have hired.the sul.centrct;,m 6. New construction 2.U_ I am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑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 required.] officers have exercised their 10.IX Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑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#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. *Contractors that check this box must attached an additional sheet showing the name of the sub-cbntractors and their workers'comp.policy information. .I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. �^ Insurance Company Name:_C/'�ji i/76� Policy#or Self-ins.Lic.#: — �� j 'q— ( Expiration Date Job Site Address: ll/ Co Ql�l: V ? City/State/Zip:�� i jiIC7/J v � _ , Attach a copy of the workers' compensation policy declaration page(showing the poUcy number and expiration dat `'// � 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 peaaalt es in the forma of a STOP VIORK 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 IDIA for insurance coverage verification. I do hereby certify under the pain d penalties of pert ury that the information provided above is true and correct Si ature: 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 6.Other Contact Person: Phone#: COMMONWEALTH OF MASSACHUSSTTS BQARDF PLUMBERS AND GASFITTERS ' I SSUES '.THE FOLLOWING L I"CENSE ?w L10EN5ED A5 ;;A MASTER PLUMBER '¢ DOSE. L MARQUEZ ,W PO BOX I LAWRENCE. . MA 01842 0001 1356h : 0 1 /Q1f16 23241 B 16 32 'COMMONWSALTH OF MASSACHl1SSTTS BOAR13 bE ELf GTR l Cl ANS I SSUES ;THE FOLLOWING L'�CENSE AS A; REG JOURNEYMAN..:..:ELECTRICIAN '� JOSE L MARQUEZ W. : PO BOX .1 .A. AN` E MA 01842-0001 39744 ....E.. o7f3:1/16 69680