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Home My WebLink AboutMiscellaneous - 1005 FOREST STREET 4/30/201896ir 1 'e Date ..... ....... /(? TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... has permission to perform ..... . ......................... wiring in the building of ........ . .................................... at ............1 '-'..8:7. ...... :5.2:7 ......orth Andover, Mass. Fee.. Lic. No.......... il RICAL i ? Check itP Permit No. 4'l -- -------- Department of Fire Services 6 � Occupancy and Fee Checked ,w BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank 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: l City or Town of: NORTH ANDOVER To the rnsiector of Wires: By this application the undersigned gives notice of his or her iptention tp perform the electrical work described below. Location (Street & Number) Owner or Tenant c Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No R" (Check Appropriate Box) Purpose of Building 1.01mea , Utility Authorization No. � Existing Service/—eo-Amps Volts Overhead Undgrd ❑ No. of Meters New Service c$&O Amps/Nc) 1.4Z Volts Overhead Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed F Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALA1iTWSJ No. of Zones No. of Switches No. of Gas Burners No. InDetection and of Initiatin Devices No. of Ran Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump ........................................................ Number.. Tons KW No. of Self -Contained Totals: 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 No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsNo. 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: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under th pains andpenalties of perjury, that the information on this application is true and complete. _ FIRM NAME: LIC. NO.: IS07 Licensee: Signature r LIC. NO.: (If applicable, enter "exen t" i the 1' ense number line.) wool Bus. Tel. No.- Address: q,_fct�—� Ct—rl`l P_ Alt. Tel. No.: 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 Owner/Agent FPE"IT FEE. $ Signature Telephone No. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: City/State/Zip: %I/a��,�� Phone #: IZE:6,�3�2 son Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 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. rkers' comp. insurance. [No workers' comp. insurance 5. Z We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑�Wemodeling construction 7. 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions 11. El Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box## 1 must also fill out the section below showing their workers' compensation policy information. fi 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: 7—ZZ Job Site Address: Z90 - &(e5 Si r City/State/Zip: !J o G 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 cer0yunder thepains and penalties ofperjury that the information provided above is true and correct. 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 #: