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Home My WebLink AboutMiscellaneous - 120 WATER STREET 4/30/2018 (8)9895 Date ...............'9....11............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that / ek �. � j�J k .��` � ............... .... .............. .............. .................... has permission to per /....................................................................... wiring in the building of . r`�C��..'........`..'"......................................................... 'LO .... UJW..-%/'/2 5 7— at ..�....................... ..................hAndover,. !rMass ss FeeJ.`ate.. Lic. No..7� ......... .....��E....... FLEC CALINSPCTOR � Check # 3 7 Commonwealth of-MassachusettsFOccupa Official use only Department of Fere Services 0q IVBOARD OF FIRE PREVENTION REGULATIONS ndFee Checked nP.,o,., APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code (Iv1EC), 527 CMR 12.00 (PLE'LSEPRINTININK OR TYPEALL WFORA&1Trnnn City or Town of: By this application the undersi Location (Street & Number) Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes Purpose of Building t"OIh Mu -gr- j } Existing Service New___ Service Amps _ --L_Volts Amps / _Volts Number of Feeders and Ampacity To the Inspector of Wires: rform the electrical work described below. Telephone No. No n BLDG PERMIT # Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Location and Nature of Proposed Electrical Work: �t til' �b lU No. of Recessed Luminaires Completion of the following table may be waived by the Ins ector of Wire No. of Ceil: Sus . No. of p (Paddle) Fans Total. No. of Luminaire Outlets No. of Hot Tubs Transformers KVA No. of LuminairesSwimminPool Above In- g rnd. Generators KVA o. o mer enc i tm El Y g g No. of Receptacle Outlets rnd. No. of Oil Burners Batte Units No. of Switches No. Gas FIRE ALARMS No. of Zones of Burners No. of Detection and No. of RangesInitiatin No. of Air Cond. Total Devices No. of Waste Disposers Tons Heat Pump 1lTumber Tons KW ....................._...._.._...... No. of Alerting Devices No. ofSelf-Contained No. of Dishwashers Totals: ..... .........................._. space/Area Heating KW Detection/Alertin Devices Local ❑Municipal No. of Dryers Heating Appliances KW Connection E] other Security Systems:* No. of WaterNo. Heaters KW of No. of No. of Devices or E uivalent Hydromassage Bathtubs Signs Ballasts Data Wiring: No. No. of Devices or E uivalent !� O No. of Motors Total HP Wiring: T OTHER: No. of Devices or Equivalent Attach additional detail ifdesired, 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 NEC 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 t4 BOND ❑ ❑ ( OTHER Sec' I certt, under the pains an penalties o er'u'7' that the inadon on this application is true and complete_ FIRM NAME: �D6W& of I Licensee:7% ,�j� LIC. NO.: Signature (If applicable, enter "ex t" zn the Zicense num e) LTC. NO,: Address: �IIDfLp r ,� Bus. Tel. No.: *Per M.G.L. c.147, s. 57-61, security workrequires Department ublic Safety "S" Lie Alt. LIC. 1�T0.: , 1p 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 a Owner/Agent m the (check one) ❑owner ❑owner's agent. Signature Telephone No. PERMIT FEE: ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL 2. FINAL INSPECTION: Passed — Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: /1� Zee/ (Inspectors' Signature - no initials) Date 3. UNDER GROUND INSPECTION: Passed — [ ] Failed — [ ] - Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 4. INSPECTION —SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed — [ ] Failed — [ j Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 5. INSPECTION - OTHER: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CRARGED. ! The Commonwealth of Massachusetts Department of lndustrial,Acczdents Office ofInvestigations 600 Washington, Street Boston, MA 02111 UqF vww.mass gov/dia Workers' Compensation Insurance Affidavit: Buuildelrs/Coniractors[Blectxicians) Plumbers t Name Please Address:? l� DOCG City/State/Zip: A% %z� % Phone#: O�% G'Z Gl`d Are you an employer? Check the appropriate box: I. ❑ I am a employer with 4. ❑ I am, a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2.7 t lam 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. workers' comp. insurance. [No workers' comp. insurance S. ❑ We are a corporation and its required.] officers have exercised their 3.El 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.] employees. [No workers' comp. insurance required.] Type ofproject (required): 6. ❑ New construction 7. ❑ Remodeling . 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. F1 Roofrepairs 13. F1 Other TAny 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 their workers' comp. policy information. lam are employer that is providing ivorkers' compensation insurance for my employees Below is the policy andjob site information. �� Insurance Company Name: Policy # or Self -ins. Lic. #: lob Site Address: Expiration Date: 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 ofup to $250.00 a day against the violator. Be advised that a copy ofthis statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Hereby certify under thepains andpenalties ofperlury that the information provided above is true and correct. Signature: Date: 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): x. Board ofHealth 2. Building Department 3. City/Town CIerk 4. EIectrical Inspector 5. Plumbing Inspector 6. Other C ontactPerson: Phone