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Home My WebLink AboutInsurance Letter - Permits #11723 - 63 CROSSBOW LANE 7/12/2013 Date..... ..C'..: µonrh,�o� 'TOWN OF NORTH ANDOVER PERMIT FOR WIRING JBgCHUg� This certifies that `` .........L 4..........�. ...�..'. has permission to perform E � .................:.. .................................................................................... , wiring in the building of...............f..'.f. ..6........:.:..:. .................................................................. " b y at ........ :... . ............. ,North Andover,Mass. Fee.......: Lic.No. ,?,y.. .. r. .,.4 P... a •.;. � .......... ELSCPRICAL INSPECCOK �� Check# s � C CfommonweaR o f Mabaac4wetta Official)Use Only 2 c� ,I [ � 2-'� epartment of Jiro Seruice� Permit No. Occupancy and Fee Checked r` 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: 6. Z 9")3 City or Town of: ko rA �-)40 clef 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) ro �oi4J L.4Pi.e , Owner or Tenant 1 Telephone No. Owner's Address 1 7 Is this permit in conjunction 05)deoce a building permit? Yes ❑ No ❑ (Check Appropriate Box) Z Purpose of Building Utility Authorization No. Existing Service 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: , )l' .eC,) L /U�l Completion o the ollowin table maV 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 Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rud. ❑ Batte 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 o.of Air on Tons,3' S No.of Alerting Devices Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers All' Totals: "` """"" """"' """" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances Kam, Security Systems: � No.of Devices or Equivalent No.of Water Kam, No.of No.of Data Wiring: Heaters Ballasts Signs 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 of Electrical Work: (When required by municipal policy.) Work to Start: 0 t1t /�.CX� Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO�GE: 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 0- BOND ❑ OTHER ❑ (Specify:) /(-519 6 rO a ^ I certify,under the pains andpenalties ofperjury,that the informal on tills application is true and completer FIRM NAME: G°u(1Iq Zee Gl LIC.NO.: )-79�� 7 Licensee: Signature - LIC.NO.: (� (If applicable;enter "exejn)t"in toe,license number line) Bus.Tel.No. �T}"r e-1 Address: e K'y- . L� y l A l D/ j Alt.Tel.No.: S` *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 Signature Telephone No. PERMIT FEE. $ f F The Commonwealth of Massachusetts Department of lndustrlglAccike is Office of Investigations to 600 Washington Street Boston,MA 02111 www.massgovIdia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information a Please Print JLeuibly Name(Business/OrganizatioiAndividual): �_ ) Le on Address: l De � ci 3 4re City/State/zip: N,%e q D/fW/ Phone#: Z7 f' e 7' 7,5 J�1' Are you an employer?Check the appropriate box: Type 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.x 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 $ .❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roofrepairs insurance required.] employees.[No workers' U n 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 tie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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'comp ensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Poiicy#or Self-ins.Lic.#: Expiration Date: Job Site Address: rCity/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or onc�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. Ido Hereby certlo a er thepains andpenaltie ofperjury that the information provided above is true and correct. - Si ature: Date: r Phone#: r 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 one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: