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HomeMy WebLinkAboutMiscellaneous - 0 Baldwin Street (3)Pi I 10390 Date ..... TOWN OF NORTH ANDOVER PERMIT FOR'WIRING This certifies that ........ ............... has permission to perform ..... Any ........ 5e-oe-4��!� .............................. wiring in the building of .... "e4t"C543 7 North Andover Mass. at ."Ae4�jDt . .... �?7 ...... / .................. -2 3? -Oe z Fee..V/ ......... Lic. No. lz .... ................. 4. .. .. ....... LEcrRICAL INS P R' Check # Commonwealth of Massachusetts Official Use Only AM Department of Fire Services Permit No. Q Occupancy and Fee Checked r 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 (MEC), 527 CMR 12.00 (PLEASE PRINTININK OR TYPE ALL INFORW TIOA9 Date: /0— City 0—City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gjves notice of his or her intention to perform the the electrical work describedd below. Location (Street & Number) /J 1 y p\ RL<- Ye G �(� C >°h dove S-+. rQ le ro � —2 Owner or Tenant Owner's Address "3 `6�{ (i 5 eAOO Q( S'2 Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No X (Check Appropriate Box) Purpose of Building Utility Authorization No. / ` 0,2— O a Existing Service 0 Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service LCZ) Amps /;7,U/ 2LIOVolts Overhead ❑ UndgrdU No. of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: / 6� �j spef) I C-Q,� 210 J Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires p• (Paddle) Fans No. of Ceil: Sus addle F ' No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ grnd. grnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FTRW ALARMS No. of Zones No. Detection and No. of Switches No. of Gas Burners -of Initiating Devices No. of Ranges No. of Air Cond. Tons Tot No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Disposers P Totals: ...........-.... Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal ❑ Other Connection No. of Dryers rY 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 of Electrical Work: (When required by municipal policy.) Work to Start: 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: INS BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, th t the information on this application is true and complete. FIRM NAME: t✓ qy� I CAVA, ' C.L C1, LIC. NO... X77 32 Licensee: r" �Q� L �.: �c&w d Qi Signature LIC. NO.: / 9 f (If applicable, enter "exempt" i the license number (line.) )L> Bus. Tel. No.-;C.j Address: /�d L.l� h � � � d f Sf e t OA �l/ rl • ©3 't / Alt.. Tel. No. I *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 PERMIT FEE: $ Signature Telephone No. ilk' -79. —7—/--- j —,, o P- —— __� ► ___ _ 119 -2f-ll 01C, 16- z e It P�Q The Commonwealth of Massachusetts 1 Department of Industrial Accidents G`r Office of Investigations Z .,� / � 600 Washington Street Boston, MA 02111 www.rzzass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anolicant Information Please Print Legibly Name (Business/Organization/individual):— City/State/Zip: Phone #: . Are you an employer? Check.the appropriate box: 1. ❑ I aro a employer with 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* 2. ❑ I am.a.sole proprietor or have hired the sub -contractors _ listed partner_ on the attached sheet. ship and. have no employees These subcontractors have working for me .in any capacity, [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I din a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No -workers' comp. c. 1.52, § 1(4),' and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F7 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.0 Other - 1 -1C••.•••I) uux n 'must also nu out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a newaffidavit indicating such. ]Cont actors that check this box must attached an additional sheet showing the name of the sub -contractors aril] their !vergers' comp. petit; in:ar—adon, I ant an ernPloyer that is providing: workers' compensation ins information uPance fOP rrsy employees: Below is the policy and job site Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: 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 certify under thepains andpenalties ofperjury that the information provided above is true and correct Signature: Date: Phone #: Official use on1y. Do not write in this area, to be corrgp re 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 #: