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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....... I ....... . ........................................
................ ......... ...............
has permission to perforni/eP.4&-3/C IA -&A -r- "7-
..................................... I ...................... ....
wiring in the building, of ....... ��6 J, &// e�j .... ("
............................... ......... .......
at .... /zx r— ...............................
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..................................................................................................... ,North Andover, Mass.
Fee //05- Lic. No. /3L/L/I
ELECTRICAL**-*,**''**-** INSPECTOR*"'*''*"*"*
Check # -3�01
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C'ommonwea& o1;%a6.4ac1wdte
2epartment o0re Services
y` BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 1. ?5 12,kerl
Occupancy and Fee Checked
[Rev. 1/071 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 INFORMAT OPV) Date: 2C 2.?
City or Town of: ,gam U t-.,ev? To the Inspector of Wires:
By this application the undersigned gives notic of hi her intents n t perform the electrical work described below.
Location (Street & Number) J 3 /� ��� P (��. �-�—•
Owner or Tenant
Owner's Address
Is this permit in conjunctionXth a building permit? Yes
Purpose of Building S
Existing Service Amps / Volts
New Service Amps / Volts
Number of Feeders and Ampacity
Loccatio% nd Nature of Proposed Electrical Work:
hone No.
No ❑ (Check Appropriate Box)
Utility Authorization No.
Overhead ❑ Undgrd ❑
Overhead ❑ Undgrd ❑
No. of Meters
No. of Meters
D otP
4kV4 c re !, r- t PZ eo
Com letion o the fnllowin tablema be d b
rW
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:— 2 a— / 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 i`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 Ej (Specify:)
I certify, under the ins and penalties of perjury, that he information on this ap station is true and complete
FIRM NAME [ -e -1— 0 Gi 2 tli / G LIC. NO.: /31J41 r.1-4
Licensee: L _ Signature LIC. NO�p2fj
(Ifapplicabl , ter "e)km " i t e Iic s number line.) j/ / n^ Bus. Tel. No7 /o?�
Address: ��_�� Alt. Tel. No.:
*Per M.G.L. c 147, s. 51.1
7-61, 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: $
WalVe rrrc ono cuvr v li ca.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
o. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In -of
o Emergency Lighting
qnd. rnd.
Batte Units
No, of Receptacle Outlets
No. of Oil Burners,
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection an
Initiating Devices
No. of Ranges
g
No. of Air Cond. Total
Tons
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 Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:
No. of Water
No. 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 Equivalent
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:— 2 a— / 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 i`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 Ej (Specify:)
I certify, under the ins and penalties of perjury, that he information on this ap station is true and complete
FIRM NAME [ -e -1— 0 Gi 2 tli / G LIC. NO.: /31J41 r.1-4
Licensee: L _ Signature LIC. NO�p2fj
(Ifapplicabl , ter "e)km " i t e Iic s number line.) j/ / n^ Bus. Tel. No7 /o?�
Address: ��_�� Alt. Tel. No.:
*Per M.G.L. c 147, s. 51.1
7-61, 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
a
a 1 Congress Street, Suite 100
Boston, MA 02114-2017
Yai www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Rice & Brouillard Electric Inc.
Address: 37 Stevens Street
Haverhill, MA 01830
Phone #: (978) 372-8734
Are ,you an employer? Check the appropriate box:
1. ■❑ I am a employer with 13 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ Iam a sole proprietor or partner- listed on the attached sheet.
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
J. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] T
These sub -contractors have
employees and have workers'
comp. insurance.t
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. [] Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repass or additions
I I.❑ Plumbing repairs or additions
12. ❑ Roof repairs
13.❑ Other
*Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
i 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 must provide their workers' comp. policy number.
I urn an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name: (� .7 . `(`tom , V\r1uj_\k l� _
Policy # or Self -ins. Lic. #: GLC— Lo00— yCO'S\`J—'oZO�Uk2� Expiration Date:
Job Site Address:_—City/State/Zip:k� .i
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. 1.52 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 tine
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.
I do heryily ctrtrMupder thypsins a)rd penalties gfperjury that the information provided above is true and correct.
Official use only. Do not write in this area, to be completer) 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 #:
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