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Home My WebLink AboutInsurance Letter - Permits #12304 - 55 CRICKET LANE 4/23/2014 I . r Date ........................................ NORTH °� •`" '•,� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �, O�•1.O�fi.� BSACHUBE p .....' j� -� a This certifies that ....�... 6.. :: & .........� . F has permission to perform ..... � � F s ....................... ..... c............... wiring in the building of........ 111.1 " at .................... ......... ......: ..... .`.... . `...........;North Andover,Mass. �s >� Fee.... r Lic.No. . r......... :... ,:'.... ✓ .:... :...+..:.. ELECTRICAL INSPECTOR e Check# i _ i Commonwealth of Massachusetts official Use Only C/l ai° Gi'� f Fire Services Permit No, Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEQ,527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: '7' ' v23 •)y City or Town of: NORTH ANDOVER 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) ,fs Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a-buildin ermit? Yes ❑ No (Check Appropriate Box) Purpose of Building i-& i-r9/'v WELC-:J. A c- Utility Authorization No. Existing Servic00 Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ��`�/��c'� Ig2c �,,- u�,t J•9C Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above Ei In- ❑ o.o mergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Dis posers Heat Pump Number Tons KW" No.of Self-Contained p Totals: " ' " """'"' ' Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ElOther p g Connection No.of Dryers Heating Appliances KW SecNo.to Device s or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: .4dach additional detail if desired,or as required by the Inspector of YYires. Estimated Value of Electrical Work: 3"00, '`" (When required by municipal policy.) Work to Start: .y'613 "I Inspections to be requested in accordance with MEC 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 issuing office. CHECK ONE: INSURANCE in BOND ❑ OTHER ❑ (Specify:) Icertify,under the aims andpenalties ofperjury,that the in ormation on this application is true and complete. FIRM NAME: . x—Hcr LIC.NO.: ��/`61 Licensee: h � uYc�a✓tv/ 'tl/ Sigma ur LIC.NO.: (If appli cab le, ep to "exempt"in the licen numbe�Iyze.) /�/ Bus.Tel.No.:>7d" 6� � Address: �r�� y tl/'�c G �`► �/�-� t �'Y �S/ 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: 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 ofMassachusetts Department oflndustrlglAccidents Office of Investigations 600 Washington Street Boston,MA. 02111 www.mass govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Flumbers Applicant Information Please Print I,egibiy Name(Business/Organizationgndividual) ---rT tlF:5 re)u` o V P-1 7'_'� q N , Address: City/State/Zip: V" `PC_A0:tV6_ Y 09 Phone#: Are you an employer?Check the appropriate box: Typo of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors `2 I am a sole proprietor or partner- listed on the attached sheet. 'l� ❑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 10lectrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I L n plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.[l Roof repairs insurance �ired.re q u i 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. i Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such, tContractors that checkthis 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 pro workers compensation insurance for my employees. Below is the policy anti job site information. Insurance Company Name:. Policy 0 or S elf ins.Lic.ff: Expiration Date: — Job Site Address: City/State/Zip: Attach a copy of the workers'comp ensationpolicy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o. 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Hereby certify uncle• \' Pgtp.enallies ofperjury that the information provided above is free anti correct. - Signature: Phone 4: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License 0 Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other - Contact Person:-, Phone#: COMMONW _ EALTFi MASSAM-IUSETTS ® ® ® ® ® BQA D OF ELEGTRtCIANS ISSUES THE FOLLOWING L1`CENSE. AS A REG J0 URN EYMAN ELEGTRIC1kN JAMCnS S KOUYOUMJI'gN �a z 65 LOWELL RD W U ; (. NORTH .READ 1NG ; MA 01864-165' 51619 F . . O7/3l,/16 27440