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Home My WebLink AboutMiscellaneous - 123 MAIN STREET 4/30/2018 (4) Date....... �.. 7-.0 HORT,j TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACMUSES This certifies that .......... �` -l.?.!��....... .... ..................... has permission to perform �.T U/o ............ ........................................ wiring in the building of h/ / L-7-y S FI Go�/ fi T ..... ............ .. . ........ at/d.3. M�/.v ST �ti''" C �I�Sf ko > ................... . . orth Andover,Mass. Lic.No.. - ....:�?�1.............. . ..............� ...... ELECTRICAL INSPECTOR Check # 8355 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 1 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 PRINT ININK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER 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) Owner or Tenant N L } `t '7—,Q usl_ Telephone No. 1-1 -SS5:5- Owner's Address i?-S- ~-foj UAJ; 4- Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Boz)/bI C^ySG7 Purpose of Building Qj7L[ j,Utility Authorization No. i 9 � Existing Service 1666 Amps 17 0 /20 T_ Volts Overhead ❑ Undgrd,®/ No.of Meters /0 New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion.othe followin table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceff.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- El o mergeney ig g rnd. nd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.o Detection and InitiatingDevices No.of Ranges No.of Air Cond. Tans No.of Alerting Devices No.of Waste Disposers eat pump umber _Tons_ KW No.of Self-Containe Totals: Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Municipal focal❑ Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of Devices or Equivalent KW No.of No.of Data Wiring: Heaters Si s Ballasts No.of Dvices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent ' Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: / V,Ga:),"` (When required by municipal policy.) Work to Start: 1`/)-Q Ir 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 0 BOND ❑ OTHER ❑ (Specify:)pmt° eL'/3CeW` - l ' :5--19-Q91 I certify, under the aims and penalties o�erjury, that the information on this application is true and complete. FIRM NAME: 1-30____ �� 0 LIC.NO.: /J�s Licensee: / ldfN iftG�O� Signature LIC.NO.: (If applicable, enter " empt"in the license number line.) Bus.Tel.No.: 4 /__1yV_ � Address: �� S cs .5% 0/9?6 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 El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ' The Commonwealth of Massachusetts Department of Industrial Accidents f Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): � D ` Address:r7�)(D City/State/Zip: !34- &oil ,Wf f 9 26 Phone Are you an employer? Check the appropriate frog: Type of project(required): 1. I am a employer with 4. DI am a general contractor and I employees(full and/or part-time).* have hired the sub- 6• ❑ New construction P ) contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. T 7• ;N Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9• ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ME]Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11-❑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' comp. insurance required.) 131-1 Other +Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. 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. 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: S- Job Site Address./ �5 �li�%u� S City/State/Zip: �%J,� 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 copyy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. !I do hebunder the pa' s d alties of perjury that the information provided above is true and correct Signatu�re- Issuing PhoneOfficial use only. Do not write in this area,to be completed by city or town officialCity or Town: Permit/License# 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#: Date....... NORTi� TOWN OF NORTH ANDOVER PERMIT FOR WIRING �,SSACH This certifies that .........../.. �- ...... 1� /2.!..4...................... has permission to perform ............ ..�7 L................................................... wiring in the building of......5�0-1....4-.p U&27-,1.... at/09. P� STZ..... .(,/4.// ,North Andover,Mass. Fee./.?A` Lic.NoJ.. Y- EL CTRICALINSPECTOR Check # 8357 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked (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 PRINT WINK OR TYPE ALL INFORMATION) Date: I-/ —OR City or Town of: NORTH ANDOVER 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) A7 SAI S UtN �- O Owner or Tenant n 772 cr s T- Telephone No. -S5b SS5_5_ Owner's Address i7_5- Is LSIs this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Boz) /O(& Purpose of Building&—I _V,&.4 LL 1 lel Utility Authorization No. r Existing Service 1660 Amps 17-0 /20 V- Volts Overhead ❑ Undgrd,N No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Com letion.o the ollowin table may be waived by the Ins ector 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 ❑ ❑ o.o Emergency ig g rnd. rnd. Batt= 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. ° Tons No.of.Alerting Devices No.of Waste Disposers Heat Pump Number Tons_- KW No.of elf-Contained Totals: - Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ �� Connection No.of Dryers Heating Appliances KW Security Systems:* No.of WaterNo.of Devices or E uivalent KW o.of No.of Data Wiring: Heaters Si s Ballasts No.of Dvices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent ` Attach additional detail if desired, or as required by the Inspector of Wires. + Estimated Value of Electrical Work: / .GtZV.t" (When required by municipal policy.) Work to Start--?-/2-,o Ir 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 0 BOND ❑ OTHER ❑ (Specify:)e,24e o9e19,L 0W- e.;k?, 5--/9-09, I certify, under the aims andpenalties ofperjury,-- that the information on this application is true and complete. FIRM NAME: T�f jcJ , LIC.NO.: /��.5 Licensee: ��ti j�i9 Signature LIC.NO.: (If applicable,enter ' empt"in the license number line.) Bus.Tel.No. 4 17 ' Address: � C/Scfe 5"% S`, &( * 2960191*116 Alt.Tei.No.• - 1 "?62 *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: $ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations tUT 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/Or anization/Individuat): -� Address: elz!�;de,, < City/State/Zip: !3A& f ,o�W 0l q?C) Phone Are you an employer? Check the appropriate frog: 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- listed on the attached sheet. $ 7• ;N Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doingall work right of exemption er' 11 � p p MGL .❑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' 131-1 Other comp. insurance required.] q ] *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 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:��) � X, Policy#or Self-ins.. Lic.#: Expiration Date: Job Site Address/62 j�/� S City/State/Zip:,06,, 'xU/`" i9 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 copyy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the pa' sand alties of perjury that the information provided above is true and correct: X� Si ature• 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): 1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: