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Home My WebLink AboutMiscellaneous - 1109 OSGOOD STREET 4/30/2018 dao Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING -40PPR : ;,SSACNUSEt This certifies that ............ ............................................................ has permission to perform ........Z/.?, 7— ................ wiring in the building of.....C14 ...........................LtJOU—) ..................................... at..... ......:51/ North Andover,Mass. Fee.1�5..f Lic. ...... ......... ......... ELECTRICAL INSPikTOR Check # CA 10894 • Official list:OnIN, Commonwealth of Massachusetts / Permit tio. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99) (lcace blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to he performed in accordance with the Massachusetts F.lcartcal Code(MEC).527 CMR 12.00 /PLEASE PRINT IN INK OR TYPE,4Lt INFORMATION/ Date: City or Town of: 1K�V a , To the InsPecior u Wires: By this application the undersigned gives notice of his or.her intention to perform the electrical work described below. Location(Stmt& Number) Oct as q Owner or Tenant t7 IAJ Telephone No. ><-Cl 75— vy Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box). Purpose of Building Utility Authorization No. Existing Service Amps ! Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: !� jd,�6 Completion letion o the bllowin table maty be%•awed by the Inspector of 10res. No.of No.of Recessed Fixtures No.of CeiL-Susp.(Paddle)Fans Trans Total Tansformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures f Swimming Pool Above ❑ In- ❑ o.of Emergency Lighting rnd. prnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones nd No.of Switches No.of Gas Burners o.o lection Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat PumpNumber Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other yCstoennection No.of Dryers Heating Appliances KW Sec bio ofDevices or Equivalent No.o atero.o o.o pats Whing Heaters KW Signs Ballasts No.of Devices or&quivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications rung: No.of Devices or Eauivalent OTHER: Attach additional detail(/'desired.or as required hr the/ttspecror 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 cov ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) /, (Expiration(}ate) Estimated Value of Electrical Work: �y7. 00 (When required by municipal policy.) Work to Start: (p Inspections to be requested in accordance with MEC Rule 10.and upon completion. /certify.under the pains and penalties of perjuty,that the information on application is time and complete. FIRMNAME:'kAm EtecTricfil jqC •0 LIC.NO.:M P,-10 9$ Licensee:F%d0F,r r m a 1^r)eY►914 0 Signaturit LIC.NO.: /lf applicable,enter " '•in the I"cense number h Bus.Tel. No. Address: " `J Z 1'CW Alt.Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee ces no, have the liability insurance coverage normally required by law. By my signature below, 1 hereby waive this requirement. I am the(check one)❑ owner ❑owner's age Owner/Agent -- Signature Telephone No. PERMIT FEE. $ /" 1 7� 1�z 3 � �- �Y/ L13-r- el�e3,? • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 10 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/('ontractotrs/Eleetricians/Plumbers ADplkant Information Mew Print U ibly Name(Businessl(hganiiation/Inditidua1):-3-AYN, E IBCA C A _- Address: ya C A'S 1t__ '5T City/State/Zip: 5jok,,3e N I&M_ 10 Yj C7,;Z 1%0 Phone H: _7% ( q Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I b. E] tiew construction employees(full and/or part-time).• have hired the sub-contractor 2.❑ I am a sole proprietor or partner- listed on the attached sheet. = 7• ❑ Remodeling ship and have no employees 'These sub-contractors have 8. ❑ Oemolition working for me in any capacity worker' comp. insurance. y, ❑ Building addition (No workerscomp. insurance 5. We are a corporation and its required.] officers have exercised their 10.[] Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per Wil. I LEI Plumbing repairs or additions myself. (No workers'comp. c. 152. §1(4).and we have no 1_.❑ Roof repairs insurance required.) ' employees. (No workers' 1; ElOther ,meq {(V�f comp. insurance required.( 0, •Am,applicant that dw&s ben a I mtc t alu,1111 out fhe sciaiiin holo%%hawing thou%iirki m comprn%ation pdic� infiwmrtKm f kxnenw•ners who submit this affidavit mdtcmmg,thcr arc Hiring all%tali and then hire(rotstdc cAvmraltws must whmtt a nCw afl'ida+it tndicattng weh :Contractors that dKd:this box must attadted an addititwul shut shim mg the name of the%uh-contramw%and their wtwtccrs awnp.ptrlic% tnfonttatttrn l an eonl tr that is providing workers'compensation insurance for mW enfpk eet Below tic the pallet•and job sine imformttatiom. Insurance Company Name: ADa RISK. Se rv,ce .-j , I oL c.0 rlvr,i�rj _ Policy++or Self-ins. Lic. tt: kj o(a q q c) r, 7 c M(A I xpiration Date: 7/ Job Site Address: lid y (' Gf DD S-F - - -_ —Citx State/sip:tJnl+4 �JtJOor��wJtq p(�ycj 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 M61,c. 152 can lead to the imposition of criminal penalties of a fine up to S 1.500.00 andlor 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 ma% be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebyd penadies of perjury that the information provided abov a is true and correct. yr D- 6'17/Jv2 'bone#: Oftkial use only. Do not write in this arra.to be completed Ay c•irr or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.Cityrrown(Clerk a. Electrical Inspector S. Plumbing Inspector .Other Contact Person: 6 : Phone#: