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HomeMy WebLinkAboutInsurance Letter - Permits #13031-1 - 35 CRANBERRY LANE 1/14/2016 Date.... .......... TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING CH .................. ............................................ This certifies that ........... ............. ........................................................................ has permission to perform .......... .................... z"-Lj ................................. wiring in the building of........... ....... ............. .. rth Andover,Mass. .........NQ . ......... ... .... at ........ �7..... .... ........... Lic. ........... ........ . ..................... Fee......:................... . ....... .. INSPECTOR Check# /� 0/ Official Use Only C,ornmonwealth ol/r/a��achuietf� [Permit No.Partment o1 Jire seruiceacupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank PLICATION FOR PERMIT TO PERFORM ELECTRICALWORK AP All work to be performed in accordance with the Massachusetts Electrical C (PLEASE PRINT IN INK OR TYP {ALL INFORMATION) Date: 1 � l q r f ©V eK- To the Inspector of Wires: City or Town of: By this application the undersigned gives notice of his or her intention to perforn}t electrical work described below. Location(Street&Number) Telephone No. Owner or Tenant Q Owner's Address ❑ (Check Appropriate ro riate Box) P. Is this permit in conjunction with a building permit? Yes No❑ .. � ideo Le , Utility Authorization No. �e Purpose of Building No.of Meters Existing Service Amps _1 Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ Number of Feeders and Ampacity ical Work: ) r , -- Location and Nature of Proposed Electr '� Com letion of the ollowin table rna be ivaived by the Ins ector of 6l"ires. No.of Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA Generators ��' No.of Luminaire Outlets No.of Hot Tubs ,. Above In- o.o mergency �g mg ,. No.of Luminaires Swimming Pool t.nd. ❑ rud. El Batter Units No.of Oil Burners FIRE ALARMS No.of Zones No.of Receptacle Outlets No.of Detection and of Gas Burners` Initiatin Devices No.of Switches Total No.of Alerting Devices `1 No.of Ranges No.of Air Cond. Tons i Heat Pump Number Tons....... ....................... No.of Self-Contained Detection/Alertin Devices No.of Waste Disposers Totals: Municipal ❑ Other S L No.of Dishwashers pace/Area Heating KW ocal❑ Connection Security Systems:* No.of Dryers Heating Appliances KW No.of Devices or Equivalent No.of No.of Data Wiring: No.of Water KW Si ns Ballasts No.of Devices or E trivalent 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 lfires. ( q Estimated Value of Electrical Work: (When required by municipal policy.) .�` _ J Inspections to be requested in accordance with MEC Rule 10,and upon completion. Work to Start: the owner,no INSURANCE COV RAGE: Unless wai ynclud ng"completed dtoperation"cove age or its substantial equivalent. The ss the licensee provides proof of liability insurance undersigned certifies that such co erage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) cJ l^ 0 I certify,under the pairud �errulties of perjury,that the i►tfor►trat_io„nf on this application is true LIC.NO.:deomplete. E FIRM NAME. Iq L e o tl o G G-f LIC.NO.: ' �'' , •ry Licensee: Bus.Tel.No.: l (If appl{cable,ente "exempt"in the liLPycense nr��ber 1{n;7Si�gnature .) �� of ®�� ��® Alt.Tel.No.: Address: blic Safety"S"License: Lie. Department or ru *Per M.G.L.c. 147,s.57-61,Security wo requires that the Licensee does not have the liability insurance No. normally OWNER'S INSURANCE WAIVER: I am aware thaowner E] required by law. By my signature below,I hereby waive this requirement. I am the(check PE 0 owner's agent. IT FEE: $ Owner/Agent Telephone No. Signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ►vww.mass.gov/dia Workers' Compensation Insurance Affidavit. Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual):_ M Address: ❑_�rL City/State/Zip: Mr4hjeV, Phone#. �(� �(� � 753 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and t 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2jVI am a sole proprietor or partner- listed on the attached sheet. t 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.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.El Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4), and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 13.❑Other comp. insurance required.] - — *Any applicant that checks box flt must also till 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 u new at7`idavit 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 am an 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: l Ci(11 r c U City/State/Zip:__y � 02&J c)e 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 un r l:e pains and penalties of per'ury that the information provided above is true and correct. Signature: C Date: "— Phone#: (Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermittLicense# 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#: