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Commonwealth of Massachusetts Official Use Only
Permit No.
Department of Fire Services Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (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:
City or Town of. NORTH ANDOVER- To the Inspector of Wires:
By this application the undersigned gives nytice Qf his,or her intention to perform the electrical work described below.
Location(Street&Number)���� 1& via V
t Owner or Tenant Telephone No.
Owner's Address CInc t(3 0A
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate]Box)
Purpose of Building Utility Authorization No.
Existing Service'�P Amps Volts Overhead❑ Undgrd F1 No.of Meters
New Service Amps Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Pr osed Elec rical'Work: "i
"A awl C,
Completion of the following table may be waived by the Inspector o Wires.
No.of Cefl.-Susp.(Paddle)Fans No.of TotalNo.of Recessed Luminaires Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
Above Fi ig ting
Swimming Pool Battery Units
No.of Luminaires grnd.
No.of Receptacle Outlets No.of Oil Burners IMF ALARMS I No.'of Zones
No.of Detection'and
No.of Switches No.of Gas 13 urners Total Initiating Devices
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
1,�I o. ic Self-Contains d
Heit p J.KW..........
Pum ion/Alerting Devices
No.of Waste Disposers rotalfl: Detect
ro.,of
ete,_t onlMertir
LO;
I n Munici
'aC 1111 '
No.of Dishwashers Space/Area Heating KW Local Connection FJ other
c ion
SeSyss
Security S stems:*
Heating Appliances KW
No.of Dryers No.of Devices or Eguivalent
No. No.of Data Wiring:
Heaters
No.of Water W Signs Ballasts No.of Devices or Equivalent
Telecommunications Wiring:
No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent_
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: Eka,,k (When required by municipal policy.) 5
Work to Start: k/L 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 [I BOND D OTHER F1 (Specify:)
I certify, under the pains a enaltiesgf erjury,that the inforniati Is lappl' , "Mon is true and complete.
"I �FIRM 1 LIC.NO.:
7 1 S J4
LTC.NO.: DN
Licensee: SiginSiatur - �5
(If applicable,en r mpt"in the license umber It Bus.Tel.No..(Qa.�-
Address: Alt.Tel.No.:
t"f Public
_�,f� " L Lic.No.
*PerM.G. c. 147,s.57-61,security work requires Department of Public Safety insurance coverage normally
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liabilityins anc c rag no a
required by law. By my signature below,I hereby waive this requirement. I am the(check one)D owner E]owner's gent.
Owner/A2eiit FEE.- $
Signature Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the e
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.1.43,§3L.
Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 1.5,2012.
❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑
❑Permit Extension Act—Permit/Date Closed:
'french Inspection
Pass M Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass Failed Re-Inspection Required($.) ❑
Inspectors Comments: -
e
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass M Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
ROUGH INSPECTION:
Pass Failed Re-Inspection Required($.) ❑
Inspectors Co ents:
Inspectors Signature: Date:
FINAL,INSPECTION:
Pass 0 Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leizibly
<
Name (Business/Organization/Individual) U J
Address:
City/State/zip: W\C,,, C;5 0:26 Phone 06 -?
Are you an employer?Check the appropriate box: Type of project(required):
El I am a employer with 4. El I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors ❑Remodeling
2.&�am a sole proprietor or partner- listed on the attached sheet. I
hip and have no employees These sub-contractors have 8. E]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.]I officers have exercised their 10.❑Electrical repairs or additions
3 E_] I am a homeowner doing all work right of exemption per MGL ll.F1 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.F]Roof repairs
insurance required.]t employees. [No workers'
comp, insurance required.] 13.n Other
Any appliqrit that checks box#l must also fill 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 a new affidavit indicating such.'
�ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site
:formation.
isurance Company Name:
olicy#or Self-ins,Lic.#: Expiration Date;
)b Site Address: City/State/Zip:
.ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne 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
F up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Lvestigations of the DIA for insurance coverage verification.
do hereby certify under the pains and penaides of perjury that the information provided above is true and correct.
i.gnature: Date:
Zone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License 4
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#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer,or"the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city of town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial.venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
evised 5-26-05 Fax# 617-727-7749
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