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Home My WebLink AboutMiscellaneous - 0 GREENE STREET 4/30/2018III Date ...... �7. 7. -� �-. �� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... e4. &.,-�,o ;7— ZZ5K7,OV e Z'el 11 '- ............................................... has permission to perform ... 445 12 5 ................................................................... wiring in the building of .... /P.. ..... *..' '. A� ---- ---------- at.A�A/*<�z.-,-.!�Z� ..... Mg?�K.A'� North Andover, Mass. lop Fee.# ........ Lic. No . .......... . �e .............. j ........ LWMCAL ilN�SP;ia% Check J., �.._ Commonwealth of Massachusetts Official Use Only Permit No. �J g57 - Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] (leaveblank) 1 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: /-2 - -2 2- 2.o /O City or Town of: Alo,-n ,¢,vdvtlL To the Inspector of Wires.- By ires.By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) / 1"or kes)t � 12�wNaxl /77eo-Ja-w s Owner or Tenant A/'ot-+k A,,,J0u,!,1, A61,42�, Telephone No. 97e-642 -39g.2 Owner's Address dg.�L�ici t tz>/Ci 4 Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Boz) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts . Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: Livb Ale,_/ 13 C,1 2 ,rl � a y Coe /fie ref Completion of the following table may he waived by the Tn.cnoctnr nfWirvc No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑ In- rnd. rnd. ❑ o. o Emergency ig mg Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons g No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: I.Number I Tons I KW I No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No, of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: 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. 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 ❑ OTHER ❑ (Specify:) A4e to ?, lc -,Jr 7y1. e. 3 -2 S- -'� o / / Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Date) Work to Start: Inspections to be requested in accordance with NEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: C r,& Al E -c- 60 -7ryc LIC. NO.: 1*4 // 9 / J1 V Licensee: %3 r-, A-,-� Ci1,Z.Wc Signature LIC. NO.: E a 9 20 IV (If applicable, enter "exempt" in the li ense number line.) Bus. Tel. No.; Wo- AM- 6 9 b c Address: /0 /2+iw L6 ty %err, /WcLsS o/ y.2 3 Alt. Tel. 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. $ w� 0 1'2- 9' !D sr -s t)W 2,7 3119 - .31 01-971q-2--7 14 u The Commonwealth of Massachusetts Department of Industrial Accidents u Office of Investigations w ' d 600 Washington Street aW= Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Nalne (Business/Organization/Individual): co m om le r -4 J Address: 1 U �Gt 1�1.�6 tJ %re rr Cc C 2 City/State/Zip: iI)Ohilerf 10 llZ Phone.#: F. 7So fQG Are you an employer? Check the appropriate box: 1.26 am a employer with GD 4. 0 I am a general contractor and I employees (full and/or part-time). have hired the sub -contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.) 5. 0 We are a -corporation and its 3.0 I am a homeowner doing all work officers have exercised. their myself. [No workers' comp, right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. 0 Demolition 9. F-1 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other •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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation: insurance for my employees. Below is the policy and job site information. , Insurance Company Name: NO? erla4dI _ l n✓ rC/!/� 1i1(e 6 Policy # or Self -ins. Lic. #: 1A) C. Expiration Date: Job Site Address:l Ii' prke t i MarU( ihorlc r-, 4 Ci /State/Zi ri p:N . A -r1 �e.� M/a- . 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 the pains and penalties of perjury that the information provided above is true and correct. use only. Do not write in this area, to City or Town: or town official, 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 #: