HomeMy WebLinkAboutMiscellaneous - 121 HERRICK ROAD 4/30/2018 (2) III HERRICK ROAD
210/020.0-0028-0000.0
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Date......I..2--
. ...... ...... ... ...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
CHU
This certifies that ..........L.. .. .. .... . .. . .. .... . ............... . ..............
has permission to perform ......... . ......60-141M-411- ................
wiring in the building f . ...................................................
at...........l. &1 47C
.................. ............ North Andover,Mass.
35 47
Fee..................... Lic.No..157N.4:........
ELECTRICAL INSPECTOR
Check #
10538 .
-� l,otntnontvJ4 of/ 466aclrelk Official Usc Only
c�� Permit No. M'37_39`2epattrnent o/„fire Services
Occupancy and Fee Checked
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 PRINTW INK OR TYPE ALL NFORMATION) Date: la LS-1 090
I
City or Town oh /V(/v'j Z-I /jY\doy( To the Inspector of Wires.
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) /A J /)e 12 r2, Cc ST R� 'j—
Owner or Tenant L`1 h t,1 e /L L-t—H Telephone No. 0 57'7SI, 600
Owner's Address 1 I+ l::t2(Z 1
Is this permit in conjunction with a building permit? Yes [A No ❑ (Check Appropriate Box)
Purpose of Building p,3�_L"cc Utility Authorization No.
Existing Service dao Amps /" / dL4) Volts Overhead Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Locatioo�n-and Nature of Proposed Electrical Work:
Completion of the ollowin 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
AboveIn- o.o Emergency Lighting
No.of Luminaires Swimming Pool nd. ❑ rnd. ❑ Batte Units
No.of Receptacle Outlets /' No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No. Detection and
Initiatin Devices
No.of Ranges No.of Air Coud. Tonsi No.of Alerting Devices
No.of Waste Disposers Heat Pump umber Tons KW No.of Self-Contained
p Totals: Detection/Alerting Devices
Municipal
No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ Other
No.of Dryers Heating Appliances 1<W Sec
N of D vices or Equivalent
No.of Water No.of No.of Data Wiring:
Heaters KW Si. Ens Ballasts No.of Devices or Equivalent
No.H dromassa a Bathtubs No.of Motors Total HP Telecommunications quiv
Y g No.of Devices or E uivatent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Ifires.
Estimated Value of Electrical Work: I(A S 00 (When required by municipal policy.)
Work to Start: 1 d)IS-)X011 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,raider the pains and penalties of perjury,that the information on this application is trite and complete
r I
FIRM NAME: t�1/1�vt C_q-, ��,ec.�+-'�cu L -�C/"yc-Co� , ,..,c�P LIC.NO.: tq-i 5 7 t 9
Licensee: r 4 t2. l'"t >--te rr—" Signature LIC.NO.: 4/S 7/
(Ifopplicable,enter"exempt"in the license number line. Bus.Tel.No.: 5?ff�-(o r 7
Address: P0 ./3L,& 7 57 V �'!t _V& A-1 /lq,*- 01` 9V9 Alt.Tel.No.: 4j X - &,A?,'r 5 �(
*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 f PERMIT FEE.$
Signature Telephone No.
i
The Commonwealth of Massach usetts
Department of Indintrial Accidents
Office of Inves#igations
600 Washington Street
?� Boston,MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information T Please Print Legibly
Name(Business/Organization/Individual): t M VLLQ t J �' `c` –
Address: y 130 ?g 7
City/State/Z`1 -`c A r1 �c/ ? Phone#: 9 7 ` p ? 0
Are you an employer?Check the appropriate box: Type of project(required)-
I J&am a employer with 3 _ 4• ❑-I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. O Remodeling
These sub-contractors have 8. ❑Demolition
ship and have no employees employees and have workers' -
working for me in any capacity. 9. ❑Building addition
insurance.
[No workers' comp.insurance comp. k0. Electrical repairs or additions
5. [❑ We are a corporation and its ❑ 1?
required.) officers have exercised their 11.0 Plumbing repairs or additions
" 3.❑ I am-a homeowner doing all work. right of exemption per MGL
myself. [No workers' comp. 12.❑ Roof repairs
c. 152, §1(4),and we have no
insurance required.)fi 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.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they irlust provrde their workers'comp.policy number.
I am an employer that t Is providing workers'compensation insurance for my employees. Below is the policy anajuu site
infornm ion.
Insurance Company Name:—C v,C"r S /
/,t f� j /� (G,�/'7 Expiration Date: 6 r 't°- 'l 2
Job Site Address:
policy#or Self ins.Lic.#: '
Ci /State/Zi I1�0�'� cr'JZ'
� o�� f-� e ✓-/-��� Sf-- �' p=
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 certify under thepains andpenaliies ofperjury that the information provided above is true and correct.
Signature: Date:
Phone#:
L
l use only. Do not write in this area,to be completed by city or town official
- r Town: Permit/License#
g Authority(circle one):
rd of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspecto:r5. r
er
ct Person: Phone#:
9232 Date. .
"°RTM TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
,SSACMUS6� S
i
This certifies that .�!!�� O.�Q-f. . -r�vy4.S. .AA. . . . . . . . .
has permission to perform . / � / '0". .
plumbing in the buildings of . .fir:/,7!I. . . .��/� 11. . . . . . . . . . . . . . .
at. . I?� . h!P�r-/C� �Z1?/. . . . . . . . , NorthAndoyer, Mass.
Fee. ?v .Lie. No../.-1 Z3�r .t . . . . . .
PLUMBING INSPECTOR
Check # SU
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
Cit Town: B r4,k A-V) 1 (',i MA. Date: l L
--� / Permit#
Building Location: a
Owners Name: vlrl
Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential
New:❑ Alteration:❑ Renovation:y Replacement:❑ Plans Submitted: Yes❑ No❑
FIXTURES
DEDICATED
2 SYSTEMS
Z
LU
v0 V)
ZLn
En Ln W 0
CA U
LU tv
a Q m Ln � a En �~ W Q vF-i YO a Fes- N N w FW-
❑ LL Fes- w p O O w Z
w U }Z- X a E- u Z a u a x a S w W C o5 O w 3
in O O F-
a m m o o L. _
-SUB BSMT. a 3
BASEMENT
1ST FLOOR
2ND FLOOR
3R°FLOOR
4T"FLOOR �r
ST"FLOOR
6T"FLOOR
7'FLOOR
8T"FLOOR nn ff ii
lnstallis�gC,.,s�dp&ny rdame:_I�11 1Cts �AV✓,, f�f17 C;i'�ekC�roe O;if} Ccrtific to i
Address: � �. t ❑Corporation
I �J City/Town:it�ifV�.1,QrVl State•
❑Partnership
Business Tel:�� -�j 3n Fax:
-AiLA ❑Firm/Company
Name of Licensed Plumber: '( [as
INSURANCE COVERAGE:
1 have a current tia
_ bility Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes EJ'No❑
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy. Other type of indemnity ❑ Bond
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Si nature of Owner or Owner's A ent Owner ❑ Agent ❑
1 hereby certify that ail of the details and information I have submitted(or ente d) a riling this application are true and acc urto , <
Knowledge and that all plumbing work and installations Performed under t pe ,s�sued for this application will be in comp)an eowith all 'o,r y
Pertinent provision of the M sachusetts State Plumbing Code and Chap r 1
f e Ge eral Laws.
3y
Type of License:
itle [plumber Signa ure a sed Plumber
Ity/Town Master '
PPROVED(OFFICE USEONLY) ❑Journeyman License Number: -��
The Commonwealth ofMassachusetts
Department oflndustrialAccidents
Office of Investigationg
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/Organizationgndividual): I IG S
Address; ,
City/State/Zip; ) Phone#:
Are u an employer?Check the appropriate box: _
I FOd
project(required):
1•LJ I am a employer with. ?L 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractorsew r'
construction
2.❑ I am a sole proprietor or partner- listed on the attached shget. temodeling
ship and have no employees These sub-contractors have emolition
working for me in any capacity, workers'comp.insurance.
[No workers'comp.insurance 5. ❑ We are a corporation and its lding addition
3.❑ required.] officers have exercised their ectrical repairs or additions
I am a homeowner doing all work right of exemption per MGL umbing repairs or additionsmyself. [No workers'comp. c. 152, §1(4),and we have no
insurance required.]f em to ees. of repairsp y [No workers'compinsurance required.] her
!Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
7 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 workeisI comp,policy information.
lam an employer that is providing workers'
incompensation insurance for my employees Below is file policy and job site
formation.
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 a 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 y a st the violator. Be advised that a copy ofthis statement may be forwarded to the Office of
Investigations of e D for insurance coverage verification.
I do hereby rti eider to ins andpenalties o
P fperlury that the information provided above is true and correct.
Si natur Z j
Date:
'hone#: - 0
Official use only. Do not write in tills area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board.of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person:
Phone#:
' 1
Information and I
. nstructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance-or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers;compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy;please call the Department at the number listed below. Self-insured companies should enter their
,self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom '
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/license applications in any given year,need only submit one affidavit indicating current
Policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
xhe Col`n`xtonweai.Lh of Massachusetts
Aepaftent of Industrial Accidents
®dice of Investigations
600 Washington Street
Boston;MA 02111
Tel.#61.7-727,4900 ext 4406 ox 1-877-MA.SSAFE
Revised 5-26-05 Fax#617.727-7749
Www.mass.gQv/dia
Alk Commerce Insurance-
The Commerce Insurance COmpanysM
C1c Citation Insurance CempanySM
SM Members of The Commerce Group,Inc.'"
CLAIMS DEPT. 11 Gore Road,Webster,Massachusetts 01570 (508)949-1500
www.Commercelnsurance.com
October 28, 2011
BUILDING COMMISSIONER or Board of Health or
INSPECTOR OF BUILDINGS Board of Selectmen
TOWN/CITY HALL Town/City Hall
N ANDOVER MA 01845
RE: Our Insured: LYNNE A ALLEN
Property Address: 121 HERRICK RD
Policy#: BBRQTR
Date of Loss: 10/28/2011
Filek XXY588-VTXX67
Claim has been made involving loss, damage, or destruction of the above captioned
property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143,
Section 6 to be applicable.
If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate,
please direct it to my attention. Please reference the above captioned insured, location,
policy number, date of loss, and file number on any correspondence.
VIRGINIA GERVAIS Telephone: (508)949-1500 Ext: 11422
Claim Specialist, Casualty Toll Free: 1-800-221-1605,Ext:11422
On this date, I cause copies of this notice to be sent to the persons indicated above, at the
address above,by first class mail.
October 28, 2011
I
! rir .rr.l j .1I..
Comm r m ni
G o Co as es .... W W COME R
o GROW ini us
CIC 254 (Rev.4/95) MAIL. I38
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or
Inspector of Buildings
1600 Osgood Street
North Andover, MA 01845
RE: Insured: Lynne Allen
Property Address: 121 Herrick Road
Policy Number: BBRQTR
Date/Cause of Loss: 10/28/2011, Water Damage/Leak
File or Claim Number: 25499-R
Claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER
143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS,
CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and
include a reference to the captioned insured, location, policy number, date of loss and claim or
file number.
Ryan Werner
On this date, I caused copies of this Notice to be sent to the persons named above at the
addresses indicated above by First Class Mail.
�� r Ll_
Signat a and Date
l�
ANDERSON ADJU fMENT CO., INC.
50 Nashua R ad, Suite 303
PO Box 1098
Londonderry, NH 03053
IUvvry UP tj.lvuuvr;x Commercial: Sewer Ejection Pump: $25.00
ELECTRICAL PERMIT FEES a) including photovoltaic & Signs: $25.00 each ballast
(Effective Marclz 12, 2003) generating Equip Per KVA $1.00
Smoke & Heat Detectors &
11'INl1\ UM PE7t1viI> FEES b) un-interruptible power systems, ,
Initiating Deices:
RESi1,�F,N�,FiA'"L $25 00 per KVA $1.00 b
Residential: $1.00 each
C;ONIMERGTL.:$SO::.O:O c) batteries over 100 amp. hours, per Commercial: $60.00 up to 10
N �1
G SE CABLE O) t� cell $1.00 devices over 10 - $1.00 each �
)UTS.IDE OF .BUILDING Heat Devices: $1.00 each Space Heaters: ['
.r Conditioners: $40.00 each Heat Pumps: $40.00 each area heating$1.00 each
.arm Systems Security: (for fire Hydro-Massage Bathtubs/ Hot Sub-Panel: $25.00
stems see smoke/heat detectors) Tubs: $20.00 each Swimming Pools:
�sidential: $40.00 Lighting Fixtures $1.00 each Residential: 1 U
)mmercial: up to 10 Devices LightingOutlets: $1.00 each Above Ground: $25.00
LA
0.00 additional devices over 10- Major Appliances: (not listed) Inground: $50.00 N
�.
.00 each $20 each Commercial Pool: $100.00 f 'J
irnival Equipment: $50.00 each Motors: (per hp or fractional
part Switches: $1.00 each �
pilin Fans: $1.00 each thereofl $2.00 Temporary Service:
)mmercial New Construction or Oil /Gas Burners: (l=ust have Utility Authorization `+un,bcr
.terations: Residential $20.00 each Residential $25.00
00.00 per 1,000 Sq. Ft. of Commercial $20.00 each Commercial $100.00
)nstruction Space Office Furnishings: per circuit $10 Transformers:
)mmercial Service Change/ (Relocatable Partitions/Cubicles) a) capacitors, Per KVA $1.00
pair: Outlets & Fixture: $1.00 each b) ducts, conduit&conductors
:rst have Utility Authorization Number Ovens Built in/Counter Top Units: (Associated w/Padmount Transformers) $25
00 (first 100 amperes or fraction, one $10.00 each c') each manhole$10.00
:ter) Panel Change/Circuit Breaker: d) each handhold $5.00
each additional 100 amperes Residential: $20.00 e) per KVA$1.00 `
rpacity or fraction. $30.00 Commercial: $25.00 0 primary feeders, $25.00 each ver '1
each additional meter$25.00 Phone Jacks: See 600 volts,non-utility owned) d
)mmercial Temporary Service: datahelecommunications g) vaults and equip. $25.00 eac
00.00 Ranges $15.00 each Washers: $15.00 each
.1st (lave Utility Authorization Nuntber Waste Disposals: $5.00 each
Receptacle Outlets: $1.00 each
>mmercial Repair andRecessed Fixtures: $1.00 each Water Heaters: $30.00 each
aintenance Permit: (Blanket
rmit)up to 2 Electricians $150.00 Re-inspection Fee: $25.00
,
r pair of Electricians over 2 $50.00 Repair to Service Residential: "For Mill fl-Family'
ita/Telecommunication: $20.00 Large C;ominercial ProJect
,sidential: $1.00 per port Residential New Construction Ste Wring Inspector for
)mmercial: $30.00 up to 10 (Dwelling): $220.00
(with service up to 200 amps) pricing:
vices over 10-$1.00 each �,,, ,.,.,
!(lust have Utilit), Authorization: Number Patil I.Ceaned 5' (978) 623-83,0'6
shwashers & Disposals: for services over 200 amps see below (Ofice Fours S an: to l J Ana;,
.00 Each
a) for each 100 amps capacity or
ens: $15.00 Each fraction add $20.00
nergency Lighting (Battery Units) b) each additional meter$10.00 "11IS13CC60D. Sdht`du e
.00 each unit c) each additional panel/sub panel I R OUG UI
eders or Sub-feeders: $25.00
ch 100 amp capacity of fraction � �i��l`��i,
:reof Residential Additions/Alterations: Tl .. :d {� ti. 4L r)
sidential: $5.00 each $220.00 maximum
rornercial: $15.00 each Residential Service Change or ADDITIONAL
;/-Oil Burners: Underground Service:
$4000 INSPECTIONS �`$25.tJ 9 (il.
.
sidential: $20.00 each applicable)iti i ust have Utility Ator
ahiza::on '-�a n;bcr
mmercial $20.00 each a) one meter,up to 100 amp capacity
$40.00 (revised 07/05)
b) each additional 100 amp capacity
or fraction $20.00
Date.... �.. .`. .
E}
� NORTp
`'°;• ° TOWN OF NORTH ANDOVER
Fp PERMIT FOR WIRING
�,SSACNUS�
This certifies that �0�A� 4�
has permission to perform .......... .........&04.......................... ..
wiring in the building of..:4........../70:4/.614 .......................................
at...1.2r�....1 L�E�4 �C.!` ........Ic, .......... �..... ,North Andover,Mass.
Fee 4:' --:".o..... Lic.No:S.j .309........ . *A* r!7*
LECTRICLINSPECrO�
� Check # /,�S
7521
f n//
(fommonweahk o f Mamackujetb Official Use Only
Permit No.
► 2',partrnent'pre Servicee
!f Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEQ 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPVA
L IN ORA TION) Date: �/� ,
City or Town of: XA g To the 177spect -of ffli(es:
,r By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street&Number) X21 C
Owner or Tenant j Telephone No.
f Owner's Address S
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
r 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: Vmni
Completion of the following table may be wahled b),the inspector of Yhires.
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
r` Above In- o.o mergency Lighting
No.of Luminaires Swimming Pool 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
Initiating Devices
No.of Ranges No.of Air Cond. Total
g Tons No.of Alerting Devices
No. of Waste Disposers Heat Pump _Number on
Ts J.KY No.of Self-Contained
Totals: Detection/Alerting Devices
No. of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other
p g Connection
No.of Dryers Heating Appliances KW Security Systems:*
rJ' No.of Devices or Equivalent
No. of Water KW No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
Bathtubs No.of Motors Total HP Telecommunications Wiring:
No. Hydromassage No.of Devices or Equivalent
OTHER:
T 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 coveage is in force,and has exhibited proof of same to t permit issuin .11D,
e.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) J c,Q'JC�i�� �Z��
I certify,Guider the ai and penalties of erjury,that to information on this application is true anti cete.
FIRM NAME: ..Ju b 1 G c LIC.NO.: (5-gc3
Licensee: 510h U -A Signature A&L LIC.NO.:
(If applicable,enter "exen t''in th license number .) /Bus.Tel.No.: � ��` ��
Address: c � G �.t2Wt /"O d s Alt.Tel.No.:
*Per M.G.L.c. 147,s.57-61,security work-requires Department of Public Safety"S"License: Lie.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 PERMIT FEE: $
Signature Telephone No.
i I
luvvry yr riiv>J�vrx Commercial: Sewer Ejection Pump: $25.00 -�
ELECTRICAL PERMIT FEES a) including photovoltaic & Signs: $25.00 each ballast
(Ef ective March , generating quip Per KVA $1.00
- 122003) tiE
Smoke & Heat Detectors &
MtNrn�i?M 'E�tivlIxkEES b) un-interruptible power systems, Initiating Devices:
i2SDEN ;AL $,2S 00 per KVA $1.00 Residential: $1.00 each '
COiV11V1ERGI L-:'$50`0:0 c) batteries over 100 amp. hours, per Commercial: $60.00 up to 10 � 771 1
*",,"0 SE CABLE O." ' cell $1.00 devices over 10 -$1.00 each --
?UTS.IDE OF BUILDING Heat Devices: $1.00 each Space Heaters: r
r Conditioners: $40.00 each Heat Pumps: $40.00 each area heating$1.00 each
.arm Systems Security: (for fire Hydro-Massage Bathtubs/ Hot Sub-Panel: $25.00
stems see smoke/heat detectors) Tubs: $20.00 each Swimming Pools:
Lighting Fixtures $1.00 each
sidential: $40.00 Residential: }
)mmercial: up to 10 Devices Lighting Outlets: $1.00 each Above Ground: $25.00
.0.00 additional devices over 10- Major Appliances: (not listed) Inground: $50.00 N
.00 each $20 each Commercial Pool: $100.00 f 'J
arnival Equipment: $50.00 each Motors: (per hp or fractional part Switches: $1.00 each �
piling Fans: $1.00 each thereof) $2.00 Temporary Service:
)mmercial New Construction or Oil/Gas Burners: Nfust have Utility:A.uthorization `onmer �
.terations: Residential $20.00 each Residential $25.00
00.00 per 1,000 Sq. Ft. of Commercial$20.00 each Commercial $100.00
)nstruction Space Office Furnishings: per circuit $10 Transformers:
)mmercial Service Change/ (Relocatable Partitions/Cubicles) a) capacitors, Per KVA $1.00
>pair: Outlets & Fixture: $1.00 each b) ducts, conduit &conductors
ist liave Utility Antfrorization Number Ovens Built in/Counter Top Units: (Associated w/Padmount Transformers) $25
00 (first 100 amperes or fraction, one $10.00 each c) each manhole$10.00
:ter) Panel Change/Circuit Breaker: d) each handhold $5.00
each additional 100 amperes Residential: $20.00 e) per KVA$1.00
rpacity or fraction. $30.00 Commercial: $25.00 0 primary feeders, $25.00 each ( ver
each additional meter$25.00 Phone Jacks: See 600 volts,non,utility owned) d
)mmercial Temporary Service: data/telecommunications g) vaults and equip. $25.00 eac
00.00 Ranges $15.00 each Washers: $15.00 each
est tto}e t?titit, .luthorizarionnnrb r Receptacle Outlets: $1.00 each Waste Disposals: $5.00 each
>mmercial Repair and/or Water Heaters: $30.00 each
aintenance Permit: (Blanket Recessed Futures: $1.00 each
rmit)up to 2 Electricians $150.00 Re-inspection Fee: $25.00
Repair to Service Residential: '�1 o>1 t�' >«l ➢- ' ���`�'
r pair of Electricians over 2 $50.00 p
$20.00 Ire � e Commercial fro eci
ita/Telecommunication: 9 J
:sidential: $1.00 per port Residential New Construction gee ).Niring Inspector for
00): $220.
)mmercial: $30.00 up to 10 (Dwellingpricing:over 10-$1.00 each (with service up to 200 amps)
!Must ha}•e Utility Autlrorizatiorr \urtrt)er Paul Ke-need 5' (978) 62 3-i,7,06
shwashers & Disposals: for services over 200 amps see below (Office Hours S an, :o X1.0 ung)
.00 Each a) for each 100 amps capacity or
ers: $15.00 Each fraction add $20.00
riergency Lighting (Battery Units) b) each additional meter$10.00 111spyee ion Schedule:
.00 each unit c) each additional panel/sub panel I ROUG*[-.1
eders or Sub-feeders: $25.00 1. FJ_' ALi
ch 100 amp capacity of fraction
:reof Residential Additions/Alterations: I Trl :� �t. er<l.$ )
sidential: $5.00 each $220.00 maximum
mmercial: $15.00 each Residential Service Change or y DDI. 1ON L
/_Oil Burners: Underground Service: INSPECTIONS *S25.00' (if
sidential: $20.00 each $40.00
Ziust have Utility?1lrLtS01'IzatiOn ' tin.ber applzcttble)
mmercial $20.00 each a) one meter,up to 100 amp capacity
$40.00 (revised 07/05)
b) each additional 100 amp capacity
or fraction $20.00
