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Home My WebLink AboutMiscellaneous - 113 BERKELEY ROAD 4/30/2018 113 BERKELEY ROAD 2101047.0.0062-0000.0 Date . . TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . .142EtfU . . . . . . . . has permission to perform . .'d< . . . . S s. jr?'. . . . . . . . . . . wiring in the building of . . G'��.. . . . . . . . . . . . . . . . . . . . at . . . . .1. �.�. �= . . .5z . . . . .North Andover, Mass. �— SOff . . . . . . . . . Fee . U� . . Lic.No. . s. . . . ELECTRICAL INSPECTOR Check# .3l 7 11009 ' C..ommonwea&o////ajda4wet Official Use Only cc�� cc77 Permit No. - olJepartmertt o�.}ire�ervic¢a BOARD OF FIRE PREVENTION REGULATIONS [ Occev.j an y and Fee Checked (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• City or Town of: n To theInspector fres: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) // OwnerorTenant JI rG�,4GrTAZ TelephoneNo.97d/ld S227 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: `R/ r AN n ' Com let;on o the ollowin table may be waived by the/ns ector of Wires. No.of Recessed Luminaires No.of Ced.Susp.(Paddle)Fans TransTotal Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming PoolUn Above ❑ In- El o mergency tg mg rnd. rnd. Batte its No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No,of Switches No,of Gas Burners o.of etechon an Initiatin Devices No.of Ranges No,of Air Cond. � TonsTota5 No.of Alerting Devices No,of Waste Disposers HeatIrump Number.Tons KW No.of Self-Contained Totals: ........ ............................... DetectioNAlertino,Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances K`,1, Security Systems: No.of WaterNo.of No.of No.of Devices or Equivalent Heaters KW Signs Ballasts Data Wiring: ' No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent 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:0-7 q Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVE GE: 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 [I OTHER El (specify:) I certify,under the pains and /des ofperjury,that the information on this application is true and complete. FIRM,NAM.E;a _xi_e_s__..Electrical Service and Controls LLC LIC.N015650a Nor and Michaud Licensee: Signatur-- ,IC.NO.: 3 4 5 9 4 e (/f applicable,enter"exempt"in the license number line.) Address: 290 Broadwav suite 117 Methuen ma 01844us.Tel.No.: 978 687 0544 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ r t ' - The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigationsf 600 Washington Street Boston,Mass. 02111 wwwmass gov/dia . Applicant Information Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Name(BusinessiorganizationMdividual): �ARTESjELECTRICAL SERVICE AND CONTROLS LLC Address:-_.,2 9 0 TTTTF 117 _ City/State/Zip: MPtrMa n� Ra4 Phone#:_ Are you an employer?Check the appropriate box: I. I am an employer with Type of project(required): _ 4.0 1 am a general contractor and 1 6.0 New construction employees(full and/or part time).* have hired the sub-contractors 2 ' i am a sole proprietor or partner- listed on the attached sheet. I•D Remodeling ship and have no eenpl_oyees These sub-contractors have working for me in any capacity. employees and have workers' g•0 Demolition [No workers'comp,insurance comp.insurance.$ 9.C Building addition required] 5.0 We are a corporation and its 3•❑ I am a homeowner doing all work officers have exercised their XXL iectricarePairs or additions + myself [No workers'comp, right of exemption perm MGL 11.❑Plumbing repairs or additions insurance required]t c.152,§1(4),and we have no employees.[no workers' ]2.D Roof repairs comp.insurance required.] 13.0 Other *Any applicant that checks boa#i mast also fdl onYthe section tHomeowners who submit this affidbelow showing their workers'compensation policy information. avit indicating the, doing all work and then hire outside contractors mast submit a new affidavit indicating such. t Contactors that check this box must attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have ploy If the sub contractors have em to ees,th mnst rovide theirworkers'com . liev somber. I am an employer that is providing x1•?r_kerr'compensation insurance for my employees.Below is the policy and job site information. Insurance Company Name: . .Travellers Ins. Policy#or Self-ins.Lic_ `M - �iKUB 5B3ti851-Z�2— ExpirationDateZ/2°1)( 3: Job Site Address: r/.� 3� n A`/-&y City/State/Zip: r 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 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 ' $250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for Covera a verification. I do herby certify under the pains aced penalti per7u at lite information provided above is true and correct. Signature: 12 e2 6 Date: r/ PrinlName: Normand Michaud Phone#: 978 687 0544 V Official use only Do not write in this area to be completed c' or town by city official City or Town: Permit/license#: Issuing Authority(circle one): 1.Board of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#• ,n'n