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Home My WebLink AboutInsurance Letter - Permits #12747-1 - 33 CRICKET LANE 10/6/2015 3 Date... .......... µORT TOWN OF NORTH ANDOVER ° p PERMIT FOR WIRING 88^CHU`�� This certifies that ......................................................., ............................. . has permission to perform ....................................... .... ... ............ .......").......... .�=:................... a wiringin the building of, — ................ .................................................... , � ..... r .,y.............................North Andover,Mass. F; Lic.No. V6. .... ............. ... . ........... Fee.............................. .......:. ............................ ELECT.RI...C.AL INSPECT......OR............ Check# �`�'.'� C�a,�cnonweai'lli o� Y7/aaaachu�etl� L(1,,v,bl,,k) = c� tI a — 20,oaelment o1Jire se.�vace6 `= nd Fee Checked BOARD OF FIRE PREVENTION REGULATIONS APPLICATION FOR PERMIT TO PERFORM ELECTRICAL FORK All work to be performed in accordance with the Massachusetts Electrical Co tEC),527 CN R 12.00 (PLEASE PRINT IN 1NK OR TYPE ALL INFORII1IATION) Date: L��l -2-0 City or Town of: No�,'h aYj(,k Lr-/ To the Inspector of Wires: By this application the undersignedgilres tice of his or her intention to perform the electrical work described below. Location(Street&Number) f��/ Owner or tenant I"► r`�(. x t 1� �] �� Telephone No. Owner's Address 1s this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Ar Purpose of Building Utility Authorization No. V7 Existing Service Amps I 'dolts Overhead ❑ llndgrd ❑ No,of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Locabon and Nature of Proposed Electrical Mork: Completion of the following table may be waived by the Inspector of Wires. t j No. of Recessed Luminaires No.of C'eil.-Susp_('addle)Fans No.of I otal transformers KVA 1"To. of Luminaiire Outlets No. of-dot Tubs Generators K A No. of Luminaires Swimxining fool Alcove ❑ fin- JFNo. o.o mergency ag ng b grand. grad. Batte knits into. of receptacle Outlets Moo of Oil Burners ALAi S No.ofZoues i do,of Switches No.of Gas Burne,s of Detection and lntdatin Devices 31 Into,of ranges No.of Air Cond. Tons 1 otal 1�To. of Alerting Devices IJ^' Ito, of waste disposers Heat RumNaarnber 1 oras r�J No,of Self Container) � otals: Deh—Hon/Alertma Devices No.of Dishwashers S nee/Area a�eatina l l �oral❑ Pviaanicipai ❑ other C p b Connectioaa No. of Dryers Heating Appliances KW Security Systems.* No_of Devices or Equivalent lNo. of Water No. of No.of Data Wiring. heaters KW Signs Ballasts No.of Devices orEguivalent No.Hydroanassageatlataalas No. of lotors otal l � Teiecornnnrnnications Wiring° No. of Devices br E uavalent OTHER. Attach additional detail if desired, or as required by the.Inspector of Wires. Estimated Value of Electrical Work. $200.00 (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NIEC Rule 10,and upon completion. INSURANCE COVERAGE: 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 issuftig office. CHECK ONE: aTSuRmTCE 0 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAivm DIPIETRO H EAT!NG & COOLING ErC. NO.:A18265 Licensee: ERIK PIERMATTEI Signature LIC.NO.:40803E (If app(icable, enter "exempt"in the license number line.) Bus.Tel.No.:978-372-4111 Address. 5 SOUTH SUMMER ST BRADFORD MA 01835 Alt.Tel.No.:978-994-0725 `Per NC.G.L. c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. O-'4'4fNER'S INSURANCE W IVE;R: I am aware that the Licensee does not have the liability insurance coverage normally required by la,,v. By my sib ature below, I hereby,,vaive this requirement. I am the (check one) ❑ owner ❑ owner's agent. �.,-„-. Signature 'Telephone No. j 9 a T r�F . The Commonwealth of Massachusetts Il eparttrtent of IndustrialAccidents ' . �r = ®-ce of investigations 600 Washington Street ,, ti7ZF Boston,AM 02111 www,mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): j Pi c I ► (, fi I Cal i`yl__I,_ A r)(� 0 � 1 Address: 5 s imrn'l Sf- C-C City/State/Zip: M } Phone#: l �y ' 2 " ( � Are you an employer?Check the appropriate boar: Type of project(required): 1.E ] I am a employer with 4. Q I am a general contractor and I employees(fill and/or part-time),- have hired the sub-contractors 6. Q New construction 2_Q I am a sole proprietor or partner- listed on the attached sheet. 7. []Remodeling slip and have no employees These sub-contractors have S. Q Demolition working for me in any capacity. employees and have workers' 9 Q Building addition [No workers'comp.insurance comp, insurance.t required.] 5. Q We are a corporation and its IO.W Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself. (No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no I3.[Ph Other ? employees. [No workers' 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 ibis 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: Policy#or Self-his.Lic.#: 0` 0DIs- i7C J Expiration Date: (� "Zia) - 26( / fob Site Address: 'D D 1 `� �,(�Q. 1 (�51� City/State/Zip: N(hL'n-) , alCve/ 1� Attach a copy of the workers'compensation policy declaration,page(showing the policy number and expirations date). Failure to secure coverage as required under Section 25A o€MGL c. 152 can lead to the imposition of criminal penalties of a lure 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_corfo r the pains and pe !lies of perjury that the information provided above his true la�nd correct e: Date: y 1 (J 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#: IMPORTANT If your license is lost,damaged or destroyed;is inaccurate;or needs to be corrected,visit our web site at mass.gov/dpl for instructions to ensure the proper mailing of your Renewal Application and any other correspondence. This'license is subject to Massachusetts General Laws and regulations.Your license is a privilege, and cannot be lent or assigned to any person or entity under penalty of law. Keep this license on your person or posted as required by law and/or regulations. 9Z 81 ` `mot 'ITS 6 $t .Mkt � 1S3H1 0a13.1 d 10 tl. Hd fl-f W QVa +3 IM0110J 3141 S3nSS'l I A � Dote Town wf North Andover Your permit has been sent back to you for the following reasons: 1\ Check incorrect \ � 2) No copy of current license S\ insurance Binder not onfile ormxpired________ 4\ No Workers'Compensation Insurance /#fadevit Form Please call with any questions 978-688-9545. Fax978-G88'9S42 Workers'Compensation Form and Schedule of Fees can be found on the Town of North Andover VVebsite under Building Department. Mailing Address: 1GOO Osgood Street, Building 2O,Suite 2D35, North Andover, KUAO1845