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HomeMy WebLinkAboutInsurance Letter - Permits #11984 - 136 COVENTRY LANE 11/4/2013 Date...do��� �................ { a p10Rtl� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING $BACHUg� d Thiscertifies that ..... .. ........................................... . ............................... i u" has permission to perform .�— ............� .`.... ................................................ uilding of......:.E :. ....................................` f ....................................................... wrong in the b at ...a y ' e North Andover Mass. Fee..- ... :.. Lic.No. ... ...................................................................... ELECTRICAL INSPECTOR 11 It Check# I c i.eryo�rttt+owrww o�711aS�ae Use(( d.� /,fi�w Jsrsde+ae Perms l�o. ��.Q� �parf�.asE% BOARD OF FIRE PREVENTION REGULATIONS and Fee, APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All wo&to be pe&nwd in awor&=with the masn&useft Meewag Cods WN$27 CUR MOO (PZMSEPMT,W M OR ME AU D&O 2 70N) Date: io City or Tows.d: r'o the Ingw or of I r: Ey this avWicafiw*e ed gives notice of bis or ha-mtestm to pe&=&e electmal weak did below Lecadea(Street& owner orTeasat Telq&o"Ne.g9g-a 44 Owaer'sAddrem I^SQrflf') <-= IsddspesrmitIaaoa*wion with ab gpe !V. Yes rl. No (Che*AgpregWeBox) Purpose of BaNding. wet i I nA UtWy Av*orkadea die. .EAstiag Service Amps I Vehs Overhead D uadgrd 0 No.offers New Amps t 'vets ( eV6,e d F1 U24god of-miffs N-unber of feeder$and AmpacAy Locaden and NatttreetPro MW Electrical WormsNO.of Low the irrble •be the aJ'�u'es. No.ot8ecessed Laminalres No.efCdL-SaW.Waddle)Fans Traastamees KVA �\ e.a[LmainareOatieft No.emet Tabs Geseratoss KVAVNEW �- o.ofLamlaalres acing PadAbove Qc9 ad. 11 +d. Tiai4s �Beoep�de0atletg o.efOdBaraers @MARW- ofofZoaes N e.of5 3tes o.of Gas Damon Andes CJ Iwo N e.etRang� ofAJr Cacti. Tom AlerdagDevices ed o.afWas"Disp ONO T*=s: Names ens Spa olArea Heatbng KW ❑ Q Ober ' o.ofDryets I IOW Na. ar t o. star KW oa of Ba Data Room Sic No:ofDeviros or blWal r o.HydroatamageBaddubs of Meters ToutSP--- i Ne.otDe or aiv t OTIML. EsdmA%dVabeeofEtectacalWorIK: =000 (WbAn reT=ed W m==pd P0147 WO&to Stet: In ;:�o I I bV.W s to be rapesl ed in a=dance w&h MEC Rale 10,and upon complefim LNWRA DICE COVERAGE: Unless waived by&m ter,ao pwI t for the pX ac of l vm&may issw unless -- the licensee ptovidesptuof �Y `° ° �eaverage cr its tialvat; The =wed cues that such covemp is in andbas edit&ed ptootat same to to permit issaimS OMm CUECg ONE: RMXMCE 0 BOND © OTMR © (Spee*:) yam,wider*epaiw axdP alter thett&e; z"ox on dds qrBcaffm h&ii mKd . pffW NAM:t�r-th east Ei ectrin�t � �-�+h .l. ('art7SiD�C_.r LIC.NtL:3 1155E Liceasee:ticabIa. l�s Tel.Ne.-�9(P-(0 (4�o'7 (ifs "ass7relirenrenr�be�' • I AIL T*L v e nbSammy"S" xmse: Lic.No. pe bLG.L.a 147,s.SI-61,secuft vv&tgis lic OWN.MIS INSURANCE WANM I am awarre thatthe Lio see&4.=rotham a hwurance cove normally by laW BY mX ,f herd wave this went. I am.the{ebe,*me)C3 qmw n owner's t- � Td©pheasNo. _ PE Z'FEE.$ �� The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations ' 1 Congress Street,Suite 100 Boston,AM 02114-2017 www.massgov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Auplicant Information Please Print Leeibly Name(Business/orpmzation/individual): .No/Q rh.CAS f &FcPFIC-4L //t C Address:_ 2 v /V —2MI/1 S/. P 0 ROY 3 6 City/State/Zip: E WgkAel, Phone#: _ �!� Are you an employer?Check the appropriate box: general contractor and T Type of project(required): 1.91 am a employer with 141 4. Q T am a g employees (full and/or part-time). have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp.insurance comp.insurance. 10 Electrical airs or additions required.] 5. F] We are a corporation and its rep 3.❑ I am a homeowner doing all work officers have exercised their 1 L[J Plumbing repairs or additions myself. o workers' co right of exemption per MGL Y � �• 12. Roof repairs insurance required. t c. 152,§1(4),and we have no 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-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. Below is the policy and job site information. Insurance Company Name: l kAAQ IW591-*A�LCA _ Policy#or Self-ins.Lic.#: /1/ W C �6 Expiration Date: a �� Job Site Address:NO Qp1totN L. ne City/State/Zip:N o,An d0"6' MA n 1846 6 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 under airs a Perjury tl the information provided above is true and correct Si ature: �y Date: I 0 3 Phone# ��Sr- l 6 6— No/7 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 orie): 1.Board of Health 2.Budding Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ✓e v _ � ter„ `�.^' syi'.t'-'¢i.•�" - �C''-�'<�Sh3'�..��tir `v� 4 .ate, `'. : r