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HomeMy WebLinkAboutBuilding Permit # 1/8/2018 Jan. 9. 2018 10; 25A No. 030 P. 1 Commonwealth of Massachusefts airrolal'Use OJ4 Department of Piro services Pt No. BOARD OF FIRE PREVENT[ON REG ULATfONS [PermftFeaAssighed ev 11199] leave blaukl APPLICATION FOR PERMIT TO PERFORM ULECTRICAL WORK FOR INSTITUTIONAL* USE ONLY TWs form is for use by 1118titutions employing licensed electricians and others fan whiofi notice of electrical installations to the munioipal Inspector ofWiras is required for Work on the premises of the institution. 1f you are not an employing institution puxsuant to C.141§8 Of'the lldass$ehusetts Oenerael laws,stop here, You cannot use ibis fence. Use the standard form,only. (PIAMETBWIMNKOR?7PE,r LLMOAAM.7T'0.Aq Date: - City or Toga of: _ �' ,!fes` 7"a alae Xnspector^of Wires:this aplioadon the undersi ed ayes otice oftho on-premises pedoi-mance Af'eIootical wet ric by employees, Yustltutionyo o r (!►✓� Ao Address Loa u yU + ( Ft, y„ u v e a ALocation and Nature of Propose EleciricaI Work; M' l. Mo•, oua LS 4. =shallba 3 §3I,ofthe Massachujetts General Laws obliges those who perform electrical insiallativns to siva notice of unicipal Inspector of Wires. You may do so by filing this form_upon each Salah ocossion, or if so contour-- annual per�tit fee schedule set by the tnunicipal%ty you may maintain a eontempoxa noous log of suck work, a exhibited to the Inspector of Wires during normal.business hours without advance notica, Some ztxu dojlpali- ominal fen for annual poTmits and require 3aldividual permits for wok above a stated.magnitude. We will ale US foam on each such 000asion(chock one): YESJ v� NO [� We Wlll.rnainfain one or mote conter4ora3neous Jog(s) (check one): X135 { XQ This option is available where so contemplated by tike municipality- In these cases,you must renew this application annuaAy, and upon sigaficant changes in employment, Tho following individual(s)will be responsible for-the accuracy of tbo log(s),ifmaintaitted. You agreo that tl o log(s)will lie Iodated as indicated below. The coverage in any Individual log must be for contiguous proporty except by arrangement'1Vltlll the Inspector of Wires. �ftachs lennerrl sheets!'fPaquiredforaddilionallog7ocatlanr Lo covera a and location Where it will be tnaintaJoed Ras onslble arson L, `t s� You may maintain tba logs eleotrollieally upon agreement with the Inspector of Wires. ,If you intend to apply for such a,proce- dura,indicate below how the Inspecrot of Wires should access the log: V c uv many elec iratuts an ai system technicians(as licensed by tbo Board of'State Examiners of Elcctrloians)do you eznpIoy at your facility? Indicate the total numb of and also indicate the number offoll Brno equiva(mt staff that number includes: Total electrical employment: �� Fall-time equivalent electrical cinployment; How manyhelpers•or appreaticea do you employ to assist your lz"oensed staff anular their direct supervision(age c. 141 §8)? In general,this number must not excasd the ratio of one lieetasod ind{dual to one unlicensed Individual. Limited exceptions up.. ply for veterans(see St. 1962,c, 582 93 as amandod by St.1979,c_ I56). Indicate the total number and also indicate the num- ber offull-tfrxe equivalent stflffthattnurcber includes: Total electrical em to merit; `GA 9 p y o[�" t � dull-time a utvalent electrical employment: Not all elechioal Work fbT whial notice to file Inspector of Wires is requiredxnust be performed by Iicensedporgonnel. hear many Ruch persons,"required to be licensod,do you,have iu your employ? Indicate the total namber and also indicate the number of full-tithe equaivalent staff that nwabar Includes; Notal electrital employment.- �, roll-time equivalent elect Tical employment; &STitardons are defined,for these p=arpmes as any person,fart, or corporcltlan opeY;7tr4 under c. 1-41§8. (Please ROD traverse side£oz eerMcations and required gignature,) Jan, 9. 201$ 10: 26AM No. 0305 P. 2 Institutional permit poral,page 2 NOSE_ Some institutions enter into col*acts with contractors to perform ongoing electrical work at an inStitation,similar to ix�stitutionai employees. I£,by the terms of such a contract,your direct the performance of such work, include the num- bers of such employees ib this application. If the eantxactor ditects such pearfornnauce, of if the contract period is for tens one year, application must be made by the contractor an cite standard fo�nnm for such work. Da snot include such em- than ployem in this application. please give your official title, such as "Director of the physical Plant' or"Director of Facilities" or equivalent. Tn additiop, f ovride a statement that substantiates your authority to hixe electricians pursuant to e- 141 §g for electric W rk on the prezrnis- es of your institution,and to osta'blish priorities for the pex�orrnaWe thereof. This£oma is not to be casas�ued as a grant o£au thority to direct any licensee of the Board of State Examinffs Of Nectricians to perform work in conbraVeRtion of the rules of said Board,or in cor&avantion of the Massachusetts Electrioal Code, title is: My authority to act for the aforemerztioged Wtitutiou is, cerd ,u rger the pains nntlPe�aalties aJ perjury,incur flee information on flits appIleatlon is true and completes (SB) C (Dated) � d% (?runt lame) jyr l (work telepbozne+number) (extension) (facsimile number) a I� 9 o' is 3 Town of North Andover 1/8/2018 Quarter Check No# Amt. Pd. Receipt No# Dt. Rec'd 1 Jan- Mar 2018 199 $250.00 81691 1/8/2018 I Apr-June 2018 199 $250.00 July-Sept 2018 199 $250.00 Oct- Dec 2018 199 $250.00 Total $1000.00 Eagle Tribune Blanket Electrical Permit 2018 i i d i 0 1 i