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Home My WebLink AboutInsurance Letter - Permits #13015-1 - 63 CROSSBOW LANE 1/12/2016 Date..... ..... � y.... i Q NORTH TOWN OF NORTH ANDOVER PERMIT FOR WIRING sACHUS� i This certifies that pp� 6�` � P....t......r.....€s 9t........... . d .................................................... k l r ( �@ has permission to perform wiring in the building of .p'd.. ° �t..,... . att .. C gg .. Noftfi Andover Mass. ' � p pp _ Fee..::..: .......Lie.No. ... .. ...l..:... ..t .....c..s "� 71,b e ELECTRICAL INSPECTOR Check# `� �� Commonwealth of Massachusetts Official Use Only Department ®f Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: I IJo2//G City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives noti of his or her intention to perform the electrical work described below. Location(Street&Number) 3 /'0 SS 1, GN Owner or Tenant /`�-ei�� $ �y �' Telephone No. Owner's Address Is this permit in conjunction with a building Yes RJ No ❑ (Check Appropriate Box) Purpose of Building—5 v/e i J Utility Authorization No. Existing Service a•00 Amps /IU/oWU Volts Overhead P�[— Undgrd❑ No.of Meters f New Service Amps 1 Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed EIectrical Worlc: �o y1 C,%a CLJ J�e4, G' Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminalre Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ N—o.of.Emergency ig tmg 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 Tons No. of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained p Totals: ".""""".........."" """"" """ Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:'' No.of Devices 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: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value ofYlectri al Work ��~ (When required by municipal policy.) Work to Start: l /o�-//J� 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 9&BOND ❑ OTHER ❑ (Specify:) X certify,atn(ler the pains and penalties of pedyfp,that the information on this application is true and complete. FIRM NAME: �,� /l� T,IC.NO.: 3 G��G Licensee: 114"Q✓ 11P 1/ 11 —Signature LTC.NO.:34', (If applicable,et tier "exem t"in the license number in .) / Bus.Tel.No.; > Address: D7 I r ,)" . �✓�1,r1'1 i�l aim s Alt.Tel.No.-�M � , = 3-F *Per M.G.L c. 147,s.57-61,security work requires Department of Publ c 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 PUMIT FEE: $' Sy/ Signature Telephone No. ,. The Commonwealth of Massachusetts _ Department of IndustrialAceldents Z Congress Street,Suite 100 _ tl 021X4 2017 Boston,MA www.mass.gov/dia 0�M spy ' Walkers'Compensation Insurance Affidavit:BuildexS/ContXactors/Eiectricians/Plum ers. TO BE FILED WITH THEPERMMTTING,A,UTfloluTy- _Please Print Le it A ''licant Information Name(Business/Oxgariization/Jndivldual)' Address: O� Phone City/State/Zip:Are you an employer?Chec :rx' quType ofproject( ired): ktfie appropriate box: em to ees(frill and/or part time).* 7. ❑New�donstrh6t[on 1.❑I am a employer with P y 2, am a sole proprietor or partnership and have no employees Working forme in 8. F1 Remo delliin g ' zany capacity.[No workers,comp.insurance required.] 9, Demolition 3.�lam a homeowner doing all workmysel£[No workers'comp.insurance required.]t 10 0 Building addition q.❑,am a homeowner and will be,hiring contractors to conduct all work on my property. I will l l Electrical repairs or additions ensure that all contractors either have workers'compensation in or are sole 12_ P� birig repairs or additions proprietors with no i rriployees. I am a general contractor and I have hired the sub-contractors listed on the attached shee 5.❑ t. 13.[�Roof repairs These sub-contractors have employees and have workers'comp.insurance.t ]4. Other 6.QWe are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required] *Any applicant that checks bbx#1 mdu�1 also o y aze inglall ingwork anal hen hire outside compensationw showing their workers' ntractozs must submit affidavit indicating such. Homeowners who submit•this affi $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether o�not(hose entities, ave employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. -------------------------------- X am an employer that is providing►vorkers'compensation insurance for•my employees. Below is the policy and jots site information. Insurance Company Name: Expiration Date' Policy##or Self-ins.Lic.#: City/State/Zip: lob Site Address: Attach a copy of the woxkexs' compensation policy declaration page(showing the policy number and expiration date)• on punishable by a flilb up to$1,500-00 Failure to secure coverage as required under MGL hies in the f rm of criminals a TOPrWO1RK,ORDER and fine of up to $250.00 a and/or one-year imprisonment,as well as civil Pena day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. Do X do hereby cert under tli s ndpenalties o eryury that the information provide atrue/a correct Date• /J Si ature: �/ Phone#• �— ! 7 l Official use only. Do not writein this area,to he completed by city or town official. Permit/License# City or Town• issuing Authority(circle one): ' 3.City/Town Clerk �.Electrical Inspector 5.Plumbing Inspector 7..Board of Health 2.Building Department 6.Other Pb,one#: Contact Person: