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Commonwealth of Massachusetts OfficialYTQe Only
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Permit No.epartment of Fire Services Perm —
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
�Rev. I/07j leave blank
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 ININK OR TYPEALLWFORWTION) Date: C�_ 9 _CT
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.
I
Location(Street&NVmber) 9 Ci A
Owner or Tenant
Telephone No.�&
Owner's Address q
Is this Permit in conjunction with a building permit? Yes ❑ 0 (Check Appropriate Box
)
ox)
Purpose of Building tA�
Existing Service c;�z Amps Utility Authorization No.
)Volts Overhead ❑ UndgrdE] No.of Meters
New Service Amps I Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion of the.followin table maybe waived by the Inspector of Wires.
No. of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.of Total
Transformers KVA
No. of Luminaire Outlets No.of Hot Tubs Above ❑ In- Generators rgency ig 11 KVA
Ab No. of Luminaires Swimming Pool El
grnd. grnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners F=ALARMS JNo. of Zones
No. of Switches No.of Gas Burners No.of atection'.1nd
Initiating Devices
No. of Ranges No.of Air Con d. Tons No.of Alerting Devices
No.Of Waste Disposers ............I.Number..Taps......_........... .. . 0,of Self-Contained
Totals: ** * Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local 11 Municipal n Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Water 0.0 No. of No.of Devices or Equivalent
Heaters KW Signs - Ballasts Data Wiring:
. No.of Devices orEguivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
OTHER: of Devices or Equivalent
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: -11" (When required by municipal policy.)
Work to Start. ` -(o-J'.3 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^ BOND n OTBERE] (Specify:)
cert#% under thepains andpen0fies ofperjury,that the information o his�,v -R
A �ieallon is true and complete. C1,7
FIRM NAME:
(7) LTC.NO.
Licensee:
in the license umbeMl*ne.)
(Ifapplicab c,enter exeSignature LIC.NO.Q
Address: CYN11-1 Bus.Tel.No.- cS-1/6-
V 4- C-aTel.
*Per M.G. c. 47,s.57-6 security0 quires Department of Public Safety"S"License: Alt.' 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)Q owner n owner's agent.
Owner/Agent
Signature Telephone No. PPRWiFEE.- $ 4(J
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: in accordance with the provisions of M.G.L.c.143,§3L,the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall belled
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G1 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. 143,§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 be
ed work has not commenced or has not progressed during the preceding 12-month period.Upon written
or she has determined that the authorize
d
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.
❑ 173 of Chapter 240 of the Acts of 20-1-0 and extended by Sections 74 and 75 of Chapter 238 of
The Permit Extension Act was created by—Section 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 15,2012.
0 Rule 8—Permit/Date Closed: Note:Reapply for new permit 0
0 Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass M Failed Re-Inspection Required
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass Failed Re-Inspection Required 0
Inspectors Comments:
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass 0 Failed Re-Inspection Required
Inspectors Comments:
Inspectors Signature: Date:
ROUGH INSPECTION:
Pass M Failed Re-Inspection Required
Inspectors Comments:
Inspectors Signature: Date:
FINAL INSPECTION:
Pass F?1 Failed Re-Inspection Required
Inspectors Comments:
Inspectors Signature: Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
The Commonwealth ofltlassachusetts
Department oflndustrialAccidents
Office of Investigations
El 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/FlectriciansiPlumJbers
A licant Information Please Print L it l
Name(Business/organization4ndividual)! `
Address: ,
City/State/Zip: . ,- Phone#: &Q
C
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(fall and/or part-time).* have Hired the sub-contractors
am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
s 'p 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 10.❑Electrical repairs or additions
required.] officers have exercised their
3.❑ 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,❑Roof repairs
insurance � 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 Are doing all work and then hire outside contractors must submit anew 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.
Iam an employer that is providing workers'compensation insuranceformy employees. Below is thepolicy andjob site
information.
Insurance Company Name:.
Policy#or Self ins.Lic.#: ExpirationDate:
Job�Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 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 may be,forwarded to the Office of
'Investigations of the DIA for insurance coverage verification.
I do hereby coti inrler,,�tlZe pa' and penal ,ofperjury that the information provided'above is true and correct. -
e, °
Si afar bate
Phone#:
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#:
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 em ployeils 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 doomed 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 requ,ired?,
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicahts
Please fill out the workers,compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)narno(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLQ or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If anLT—C orLLP does have
employees,a policy is'required. Be advised that this affidavit maybe 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 thic 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 printedlogibly. 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.
Pleas,a be sure to Ell in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications*M' 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 or town may be provided to the
applicant as proof that a valid affidavit is on file for fixture permits or licenses. A now 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 advancefor 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)CommoRwDalth ofMassachnsctlM
Department of.industrial Accidents.
OfAce off"CAigations,
600 Wuhijag(on 8fteet
BostQnUA02111
TQL 617-727-4900 07d 406 or 1-8.77,MASSAFE
Revised 5-26-05 Fax#617-7277749
Vol
COIViM014WEALTH OF MASSACHUSETTS
ELECTRICIANS
ISSUES THE FOLLOWING LIOENSE �'
AS,,,. A REG JOURNEYMAN ;ELECTRICIAN
RYAN.BROOKS ,
381 PAQUETTE AVE
MANCHESTER NH 03104-1756
2 42.J.R 0 1 16 . 10086
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