HomeMy WebLinkAboutMiscellaneous - 114 BOXFORD STREET 4/30/2018 (2) / 714 )(7FOR STRE0000.0
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Date... ..l.-.
NORTH
°et+`'°:•�"° TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
��SS�cMusf�
This certifies that ......................................... �.�..... .,
has permission to perform ......... .. )A /..1.,ak .......................................
wiring in the building of........�.f ..........................................
at............f .... 0 �7 ' ....�� ............ . .North Andover,Mass.
�Dd4�---- . Lic.No..� 6S ..1 4�'e...•t-�'. �*! .........
Fee........, ....... .......1C ]ICAL INSPE&b
Check # �J
8374
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.Iffimm
Occupancy and Fee Checked
r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRIC WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CM3�/2.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:
City or Town of: NORTH ANDOVER To the Inspector fl,,' res:
By this application the undersigned gives notice of his or her intention to perform the elect//,. ork described below.
Location(Street&Number) • " �ar�a 'f'� �% i
Owner or Tenant 16.0/0 ,
,4-7`elephone No.
Owner's Address _ w
Is this permit in conjunction with a building permit? Yes No ❑ eck Appropriate Box)
Purpose of Building /.70&f J j O,,17 1 Utility Authorization No.
Existing ServiceQ_ Amps �l / Volts Overhead Und rd
g ❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
y Location and Nature of Proposed Electrical Work:
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- ❑ o.of Emergency Lighting
rnd. grnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of.Detection and
Initiatin Devices
No.of Ranges �. No.of Air Cond. TotTons 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 HeatingMunicipal
' Local❑ Connection ❑ Other
No.of Dryers ,� Heating Appliances Imo' Sectio f Devices or Equivalent
No.of Water , 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: 14.6-019, _ (When required by municipal policy.)
Work to Start: LJ-�� 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 0/(Specify:)
I certify, under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: n LIC.NO.:A1.4oil_
Licensee: ,�jy�a�,n J(jn� Signature LIC.NO.:-,,-? p G
(If applicable,enter"exempt"in the license number li e 4117Bus.Tel.No.
Address: ryE _,41� 7/3tc47`� Alt Tel.No.: - �7
*Per M.G.L c. 147,s.57-61,secUrity work requ' es ep tment of Public Safety"S"License: Lic.No.
OWNER'S INSURANCE R: I ware that the Licensee does not have the liability insurance coverage normally
required bylaw. By m ature below ereby waive this requirement. I am the(check one)❑owner ❑ owner's agent.
Owner/Age vY/
Signature Telephone No.� ��'� PERMIT FEE: S fD p �
I
��� �f� CEJ y�'�� ✓�� �-�
f =J The Commonwealth of Massachusetts
✓`' Department of Industrial Accidents
Office of Investigations
kvi 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): c 1 a4e S t )ec�r,-6
Address: - 6:0 e 12ai
City/State/Zip: �g Sora. /l�i� C)&7 Phone #: I7- Z�3 7
Are you an employer? Check the appropriate bbx: 1 Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. New construction
employees(full and/or part-time).* have hired the sub-contractors
• 2.� I am a sole proprietor or partner- Iisted on the attached sheet. 1 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp, insurance. 9. iK Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per'MGL 1 l.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12,❑ Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required.]
*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.
tContractors 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:
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.
Ido hereby certi under the pains and penalties of perjury that the information provided above is true and correct
Signatwe: `.� Date: _p� - Q
Phone#:
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#•